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APPLICATION FOR SANITATION PERMIT Permit No. "---_-- (Complete in Duplicate) Date issued 57x1-.`S-- > I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the rk here', described, This application is made in compliance with County Ordinance No. 549. At) : t ---------------- [ JOB ADDRESS ANnC;ATI N-----�.� ---- ------ ---- -------- =Owner's Name---- I�'1=j---- —----" - - ---------------- -- Phone i ----- -- ---- -------------- - --------- Z�Z Q —7 �-----` - -- -- --------.. --- ---------------------------------------------------------------------------------------------- ! Contractor's Name--- -----•-•.-- _ Phone----•------------------------------ Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1----- Number of bedrooms _y Number of baths j_____ Lot size ___C -1-- ----------------- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table --- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 204 feet.) I ix Septic Tank: Distance from nearest welL�__�_�'___-__Distance from foundation__-f�-----"--"--.Material_"___No. of compartments-----Y---------------Size__ . - +`-------Liquid depth__------------------Capacit1------ Disposal Field: Distance from nearest well-__1_0_p...Distance from foundation____1.__Q-----------Distance to nearest loth liie____�_.-------Zk YP - G gth of eacl, line------�.- ----._ Width of trench,_,- -- ---------------------- r - ``{ d T u e of filer fternmaterial_ �pth of filter material__"_ �-l�Total length-----._d--------------------------- Seepage Pit: . Distance to nearest well__)__d__Q--______Distant from f lin, t',on-_.. _____.--.Dista nce to nearest lot link__ ___-______ Number of pits--- ----Lining material �e: Diameter--- - -.+-------.Depth----- -------------------- Cesspool- Distance from nearest well-----------------Distance from foundation--------------------Lining material__---- ______-______--_-_-_____. V ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------_____Distance from nearest building----------------------------------.-____. ❑ Distance to nearest lot line----------------------------------------------- ------------ -------------------------------------------------------------- ---- Remodeling and/or repairing (describe):--- -------------- ------------------ ---------------------------•------------------------------ ------- -----•-•----------------------------------- -------------------------•----------------- ------------------------•-------------------- --- i ----- ------------------------- •------------------------------•------------------------------------------------------------------------------------------------------------ ----------- -------------------------- I hereby cer f that I have ppared this application d that the work will be done in accordance with San Joaquin County inances, Stat and rules nd reg lations of the S J qu'n Local Health District. {Si ned�.. � - --------- (Owner and/or Contractor) ------- ----- - - - t -- -- -------------------- Title (Plot plan, showing size of lot, 1 cati of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------- -- ----------------- ----- ------------------------------=--- DATE---- ------------------------------------------ REVIEWEDBY-------------------------------- ----------- --- ---------- ----------------------------------------------- -'------ DATE--------- -- DATE --- � BUILDING-PERMIT ISSUED----------------- ---- ----- - - --------------------------------------------------------- ,/�-- ------ ------------- �-- Alteratio sand/or recommendati s _ n r r !x+[. 1b-'--, ---------- .=s-- cam•. IN ` - ----------------------------------------------------- ------------------I-------------------------- ------- •---- ------ ----------------------------------- -------------------•-------------- ----------------------------------- • FINAL INSPECTION BY Date-- ---- 6--- -- ---------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street, 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Pevised W-21 DD