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APPLICATION FOR SANITATION PERMIT Permit No.TIO [Complete in Duplicate) Date IssuedA t� 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 Ordinanc&No. 549. JOB ADDRESS AND LOCATION-------------- -"N�-------- ` --------r------.---------- - ------------------ Owner's Name-`- - ----------- ------ 4 Phone----- Address ��.,._ i ------------------------------------ -------------- - --- -- Contractor's Name = � �r� = = Phone. Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ '___-Numb er'of bedrooms , -Number of baths - _ Lot size _,15� _ ��----------- ------------ ��ft. Wa+et=Supply: -Public system a�Comm unity system ❑,-r Private F] Depth to Water Table ._ �.�. , . ... ., Character of soil to.a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobp-l� Hardpan ❑ Previous Application Made: Yes ❑ NoI2"' New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: _.(No septic tank or cesspool permitted-if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation------------i____'.Material_______________________..____..---.-___.._---_. XIIDisposal Fiel Distance from nearest,well---------------No. of compartments------- ------------------Size----`---------------------------Liquid depth------------------------.-Capacity----------------------- __Distance from foundation------ .__ ._ _--_.__.Distance to nearest lot line____ --________- 4 .. Number o7 lines---------------------_ ----------Length of each line----------------------- - Width of trench _ { Type os filter material-------------------------Depth of filter mater,al-------- ---_ ----------. Total length----------------------------- -•• -� ,p1 - - Seepage Pit:,...••«.Distance to-nearest-well _ Distance f mY#9dclation�-_d_ - Di to ce fio nearest lot line_--� .-_.__ 4e_ r_Depth ! Number of pits.____.-_.___- ----Lining materia�f-{�� _-Size: Diameter_ -. �--------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------------._____-. ❑ Size: Diameter--------------------------- ----------Depth---------------------------------------,------ -----Liquid'Capacity----------------- -------gals. Privy: Distance from nearest well--------------:------------------------------- --Distance from nearesr building------------------------------------------ Privy: -------- ------------------------------------------------------ - Distance to nearest lot line---.-=,-----------,-,--- -- --------- Remodeling; and/or repairing (de'cribe):----------+ = =' 1----------------------------------------------------------- ------------------------------------------------- ----- -------------------------------------- ----------•------------------•--------------------•------------------------ ________ _ ____________________________________________________________________________________________________________ _.- -_ _____________________________________________________________________ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,'S+a+e-laws" rules, -r . ula+ions`of +he-San•Joaquin Local'Health-District. ` ( g ) (Owner and/or C tractor) (Signed) ----------------------- ------------------------------------------------------------- --- --- ' /f� [Title) 1' '2JL ------ By:--_----------------- r r +r r [Plot plan, showing size o ot, location of system in relation to wells, buildings, etc., can be lace on reverse side. FOR DEPARTMENT USE ONLY T ' l y APPLICATIONACCEPTED BY.-- ----------------------------- -------------- -- ----•-----------•----------------------- DATE_�--------------------------------------------------- REVIEWED BY-------------------- = DATE srQ-�\ BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------.....-------------- DATE----------- --------------------------------------------- Alterations and/or recommendations:------- --------- --------r--------7�------L----------------------------------------------------------------------------------- -------- --------•------------------------------------------•--•------ - --------------------------------------------------- ----------•----------------I------------------------------------------------------- ----------------------------------- -------- FINAL INSPECTION BY:..�---------------- Date--A .Z--- _77�4.r'�r-------------------------------------- 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 Revised W-2100