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x rfr rPermit No. - u ±� APPLICATION FOR SANITATION PERMIT ra (Complete in Duplicate) p � Date Issued `--' "`-� C ! - Application 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 Ordinance No. 549. JOB ADDRESS AN C TION--- ----- -------�-k-------�-------- = t -- - --- Owner's Name_ / fry.- ------- - -`---- __ Phone___��___Q Address---------_-!•-��-.-� - ------- ----- ------------------------------------------------------------------- -.. " Phone __ Contractor s Name------------ ----- Installation will serve: ResidenceApartment House-E.. Commercial E] ElTrailer Court Motel E] Other E] y t i Number of living units: _ ___ Number of bedrooms ,;� Number of baths l___ Lot size --------------------•- Water Supply: Public system Community system.ElPrivate ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑- Sandy, Loam Q Clay Loam ❑ Clay [j. Adobe Hardpan E] W Previous Application Made: Yes ❑ No, New Construction: Yes ❑ Nq, ' s TYPE OF INSTALLATION AND SPECIFICATIONS: - ll (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Q Septic Tank: Distance from nearest well-----------------Distance from foundation------------------_v-Material______________:------------------------------ No. of compartments----------------- --------Size--------------------------------Liquididepth--------------------------CapacitY----------------------- Disposal Field Distance from nearest well-----------------.Distance from foundation---------------------Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line-------- -- -----..Width of trench---------------------------------- Type of filter material_____________________ Depth of filter material_-____ Total length________________________-------.--------- Seepa a Pit: Distance to nearest wel Dis+ante f m fo dation_f1�__�____-Distance to nearest lot li Number of pits--------/--------- ining material-h.-Size: Diameter Depth . Cesspool: Distance from nearest well------------------Distance from foundation________ ________Lining material--------------------------_____..___. " als. ❑ Size: Diameter-------------------------------------Depth --------------------- ---------- qpy-Capacity 9 k Privy: Distance from nearest well______________________:-------------------------------------------------Distance from nearest building-----------.________ ❑ Distance to nearest lot line---------- -------------------------------------------------- r Remodeling and/or repairing (describe):--------------- --- ---- ---=-----------------------------------------------------------------------------------------------------------•---- ---------------•-------- ----------------------•----•------•---•-----------------------------------------------------------------------------------•--------------- - --------------------------•--------------T-- -----------------------------------------------------------------------•--------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State anZdr�e sanregulations of the San Joaquin Local Health District. (Signed) ----------------------------- Aacd (Owner and/or actor) ---------�--------------------- " --------- BY 1 =------------------------{Ti+I ,- {Plot plan, showing size of lot, loon of system in relation to wells, buildings, etc., can be nsreverse side. x FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY__ - ---------------- DATE--,]5�<=--------------------------------------------- { REVIEWEDBY - ----- --------------------- - ------------------------------------------ DATE---- BUILDING PERMIT ISSUED ___________ ____ -- _______ _ _ --------------------------------------------------------------------- DATE------- - - � Alterations and/or recommendations:_ -------- -------------- ----------------------------------------------I----------------- ------------------------------------------------- -------------------------------------------------------------------------------------- k --------------------------------------------------------- -- -- "-- ------- '-'---------- ------------ --------- - ------ - ---- ------- --- ------------- -- - FINAL INSPECTION BY ___-• -- ------------- Date--- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 81,4 North "C" Street Stockton, California Lodi,.California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 5