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APPLICATION FOR SANITATION PERMIT t Permit No. ____`l 10-_-_ (Complete in Duplicate) Date Issued -__ r�1. ,�-+. Applica4-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County,Q-rdinan e No. 544, 4 JOB ADDRESS AND:�LOCATION____ ___� _______ ______ _____------------------- ---------•------------------------------- :------------------------ ---------------- Owner's Nam -- " �;. -- -�----- --l ,--•"-Q=-Q' one------------------------------------ 5Address. ... 1- -- --------- •---•-- � tt �r -------------------•---••-•----------..------------------------------------------------.-------•-•--- i Contractor's Name____----- --------------_----- �`- •.--_ ---------------------------------- Phone--------••------------------------- I Installation will serve: Residence ® Apartment House ❑ Commercial 0 Trailer Court ❑ M tel ❑ Other Number of living units: __'-_-- Number of bedrooms �?`__ Number of baths Z_ Lot size -------------------- CAv.__� Water Supply: Publics stem Communit t y � y system ❑ Private ❑ Depth to Water Table -------- ft. r Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam [2 Clay Loam ElClay ❑ Adobe [j] E]Previous Application Made: Yes [-] No R] New Construction: Yes le"'No ❑ E TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,,,,public , fsewer is available within 200 feet) a ' Septic Tank: Distance from nearest wellr_ CDistanrre from pound tion- - later ' ❑ No, of compartments.......�_�-____._._.Size_3_ __ f X� Liquid Idep#h-__._.___._- Capacity____ - yy__ ��// i. Dispos "Field- Distance from nearest wellll ►_ _.____ _Distance from foundation_ ___ '."..Distance to nearest lot line_._ , g � , d Number of lines___ _ ____ ______�._..+> __-_____Length of each line________,�.-- a'_._.Width of trench._____.- --.- I Type of filter materi8ll Depth of filter material--------- ..------Total length----------- - --------------- Seepage Pit: Distance to nearest well..--------------------Distance from foundation--------------------Distance to nearest lot line__.__._.__-__-__. .r ❑ Number of pits----------------------Lining material--------------------.._Size: Diameter-_.-"--:-�-------- Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Size. ---- ----- Size. Diameter------------------------------------- Depth-------------------------------------- ---- -------Liquid Capacity_-------------------------gals. Privy: Distance from nearest well----------_---_-------------------------------___Distance from nearest building._____..__.____--__________._________.___. �w ❑ Distance to nearest lot line_'------------------------- ---- --- I r _ - I Remodeling and/or repairing {describe):--------- -----------------------------------•------------------•-------------------------------•----•-------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------- --------------------------••----•-------------------------•-----=----------------------------------•-------------------------------------------------------------•------------------------------------•----------------------------------------------------------- -------- --------- I——--------------------------------------------••------------------------------•----------------••-----------------------------------•• ---------------------•---------•-----•-------------------------------------------------------- } ------------------------ ----- - ••------•--------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and-re. ulafions of the San Joaquin Local Health District. U (Sig ned)..__L.04AA&--------- ---- .� ------------------------------------ -----------(Owner and/or Contractor) By:------------------- ----------------------- (Title) ------------------------------- (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). � 4 FOR DEPARTMENT USE ONLY Y APPLICATION ACCEPTED BY __ DATE x-- REVIEWEDBY------------------------- ..----------------------------------------------------------------------------._._ DATE__ BUILDING PERMIT ISSUED_�------------------------------------------------------------------------------------------------------ DATE.--- Ara+ions a /or recommendations:--=--------------- ----------------- - A '---- - -1 --------- ------- .'=--------- - 1 - � ------------------------------------- ---------- --------------------------------- -------- -- -------------------•-•--------------------------------- FINAL INSPECTION BY:---R_ ..... Date.....- _- - `� f ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street - 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r i ES-9-2M 1)5446-W000 12-54 5