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APPLICATION FOR SANITATION PERMIT Permit No. Q (Complete in Duplicate) Date Issued Applica+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 Ordin e No 49.. r It " Q Q ---- JOB ADDRESS AND LOCATION__ / -- -=•---- - `� RQ _ r'1F _T�ra Phone _'z Owner's Name_ _ ---- Address---------- .....................----------=-----=-------------=---------•- -------------'-----------------------------...------- ----------.. -------------- ----------------- ----- Phon - - _�_+Q Contractor's Name----- .fr ' I Installation will serve: Residence R ' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___�-- Number of bedrooms .1--- Number of baths __!___ Lot size .---� ^--- __�- -------. Water Supply. Public'systerh'%:Comm unity'system ❑ Private ❑ Depth to Water Table t?ff. ` 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 ❑ Noll TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s .� ictT . Distance from nearest well-----------------Distance from foundation---------------------Material_____.___-_____.________.______________-_____-. r No..of nom artmenfs-------------------- fiSize--------------------------------Liquid dept--------------------------Capacity----------------------- = p - ...Distance to nearest lot line_____ o�I Id: ,Distance from nearest weilRQ'li�._/- Distance from foundation__/. i Q-- --- ----.Width of trent �� *4.r__ ' Nu4mber oY lines--!I--------- _` � Length of each line__ _____ - Type of filter matarial_ :v- ----D+epth of filter mate ial_ .Pf___ Total length__ _ _ _ --___ -gl N.� Seepage Pit: Distance to Weare well_ IR :-_Distant f m foundatiari_ _ ........Distance to nearest lot Gne------___ ___ Number of pifs.,J> ------Lining material_- ----Size: Diamefer_,-.9.7f!-----D.pfh___A� -i9- ------------------ Cesspool• Disfance from nearest well___,____ - .__Distance from foundation -------Li material________________________ _ t , ❑ Size: Diameter------------ :€Depth------------------------------------fS '-- Liquid Capacity_. .. gals. Privy:: Dii#ance from,nearest well--'--°--------------------.------------------._._' istance from Barest building--.-----:T__________----------=---------. ❑ --_ Distance to nearasf'lot line-- '`' T �: = ------•--- -------- ----- ie i :. ------------- Remodeling and/or repairing(describe):-j------- ---=------------------------------------------------------••-•-------------------------------------------- I ---- ---------------------- ------ •---------,.i --_--------------------------- ----------- ----------------------------------...------------•-•-------•---------_--------------------------------------- y I 1._ : .1 _ ..........._ ----------- ----•--------------------------------------•------------------------- ---- I hereby ify-that l have prepared +his application and that the work will be done in accordance with San Joaquin County J ordinances, Fatlaws;and -ules and r mations of + San Joaquin L cal Health District. I { Y, r -------------------------------- r -- -- ---- R. Contractor (Signed)------ -� = I t , (Title By:------------ ----------------------------------------------------- (Plot plan, showing $ize of lot, location of system i elation to wells, Idings,'e#c., can be placed on reverse side}. t FOR DEPARTMENT USE ONLY : # APPLICATION /ACCEPTED BY........... -� -. DATE - � ------t 74------- ----------------------- --- BY-------------Z=-:°---------------- --------- ---------------------------------------------------- ----- DATE - -------------------- REVIEWED . --------------- / --------------___.----------------------------------- DATE---------------=-------------------------------------------- BUILDING PERMIT ISSUED__-•---------:------------=---------------------- t � - Alterationsand/or recommendations_:---- -------------------------------------------------- •----------------•------- -------------.._..---------------------------------------•------------ 1 s +�5 --------•---------•--=-•---•---- • - - -- l ------------ ••----- -----•---------------------•---- --------------•------------------ ------------------•- i ----- -- --------- '--- ;- s I ----• ---------------------------------------:---------------.------------------------ =-------------------------------- ----- - ------•------------ FINAL INSPECTION• BY:.. _---- ---- - j - Date--- SAN ate-=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 W-2100- ES-9-2M Revised