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APPLICATION FOR SANITATION PERMIT Permit No. __ .. .........___. ev (Complete in Duplicate) Date Issued S Applica,l,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 Ordinance No. 549. 1 ` F JOB ADDRESS AND LOCATION...._.. _ / a __-_ - ------------ - _ Owner's Name--------/ :.------- __ ..-=-- ----------------------------------- Phone,---`-------`-5--`5 { Address _s.�'�-------------•-------- --------�-------- --------------- ---------- ------------------------------- ---------------------------- Contractor s Name-------------------=-------!L _..-CSC. '------- ---- - -------•--- -- --- ------------------------ Phone .4----A!6 -f Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __-- Number of bedrooms . Number of baths Lot size ___--�__--,X 1l d_______________________ Water"Supply: Public:system Community,system ❑'"'Private'❑ Depth°to Water.Table-5/4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gra , , vel E] Sandy,.Loam ❑_,Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ 4i Previous Application Made: Yes ❑ No NK New Construction: Yes ❑ No� F TYPE OF INSTALLATION AND SPECIFICATIONS-` 1 / ' 'r (No septic tank or cesspool permitted if`public sewer is vailable within 200 feet.) �. ., - Se 'c Tank: Distance from nearest well_______________ Distance from foundation--------__----------Material--------------------------------------_-_____-- ` No. of compartments---------`Z------------ Size....-----------------------:...Liquid depth--------------------------Capacity------------------ D• RWpsal Field. Distance from nearest well----------_-.__..Distance from foundation.-------------------Distance to nearest lot line----------------- Number of lines------------------------------------Length.of.each.line--------------------------t-Width of french--.----------------------_-.-------- T e os "filter material------------------------ of filter material----.------------t_�__Total length_-.-_-__-________ "-___-_--_ '___-____- Seepage Pit: Ditance to neares 't well_._ILC_(� l _ istanc, fo ildation Q__:____.D�stance to nearest I t line_ \ Number of its.__./_ ___Linin material_ Size: Diameter=!_._ '4/_. ' Cesspool: Distance from nearest well-------- Distance`from'foundation 7"--.__---(Lining material------------------------------_______- ! Priv D sta�le mrotmr neare -__ ---_p ------ - ?DeptJ---------------------------------Distance from neatiquid Capacity----------------------------gals. r • °st well ! ; rest building ---------------- [] Distance to nearest lot line-.-.----)--------- --------------------------`-------------._:_-"----------------------------------------------------------------- ------ l Remodeling and/or repairing (descriUe):-�-----------• ------------------=-----•--•--•=----•------------------•--- -------i--------------- `r � 'l a --------- ----------••-•-----------------------•1 - --------------•-•---•------------------ ------------•--------------------._"--------•=---•---------- -=---------------------•--•---------------------------------------- -------•-•---••-----------------•-------------•----------- ---------.........---•----•--..__..---------------------- -------------•-----------------••-----------•--------------•--•--------------------------------- ... ,,....._A , f, 1 ------------------•--------------------•--------------------•-------------------------•---------•----}-----•------------------------------------•-----•----------------------•----------------- ------------------- I=`.hereby- tify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, S a, aws; a rules a egulations of the San oaquin Local Health District. a , S (5igned)_ --- - ------ •----- (Owner and/or Contractor) e ---------------- 0'3 " '. -----:------ tle (Plot plan, showing size of lot, location of system in rel on to wells, buildings, etc., can be.placed on reverse side). i FOR DEPARTMENT USE ONLY �I APPLICATION ACCEPTED BY DATEr --------.- REVIEWEDBY------------------------ -- ---------- ---------- DATE -.- BUILDING PERMIT ISSUED-- ------------'------------------------•- ----------------- -------- -------- ---. DATE Alter tions and/or recommendAtions:--------------r.._ f ----•---- - y ...%/ 411 .".:1�±- "t: 16. }' .e.'`r - '°' 'i -'' -*t __ �s ': .6�J[ e .-r,� - #_ " (j fr `�w f �- i u ' '"�_ -.rr"—a�f¢.E- _. sem' -•-- ---------- - "=:r' -`'-" -=-='----r ---- - - ------ - --- ----- -----•-- -- - --------------------------------- ------------ t FINAL INSPECTION--BY:_-- --- ..� :- Date_ -7r-- -O.,_; 3---=------- SAN JOAQUIN LOCAL HEALTH DISTRICT - 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100