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1pr j APPLICATION FOR SANITATION PERMIT Permit No.� ...Z... (Complete in Duplicate) _{' s'- Date Issued _ __a_____ s 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. 549 Q JOB ADDRESS AND L CATION--+------ - J -------- `� ----------•----------------------------------------------------------- ---- Owner's Name _ .... ---------• Phone f Address----------------------------•-•------------------------------ ------------------------------------ I Contractor's Name --------------------------------•-------------------------- -------- Phone------------•--•--•------ } Installation will serve: Residence 4 Apartment House ❑ Commercial [❑ Trailer Court ❑ Motel ❑ Pfher ❑ rr7 i� Number of living units: -1-.___ Number of bedrooms umber of baths ___�____ Lot size __________f- -a:_, --- __ _d_-_____-____--__ Water Supply: Public system ❑ Community system ❑ Private o Water Table .------- ft. f 5 'Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q--•H-6-rdpan (] J Previous Application Made: Yes ❑, No: !. low Yes I;;- o 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---4�----_Distance from foundation----- _�_------Material___�4'l!L. _ ________ _. _____. X' No. of compartments-__- �_-------Size--- _. x_. !---Liquid depth______-4_"_-______Capacity_______F¢v_`____ Disposal Field: Distance from nearest wel --- ' ____Distance from foundation_____l_U_--------Distance to nearest lot line i- } Number of lines----------- Len th of each line______ __ 2__-_-____.Width of trench_______ g `, H� -------------- Type of filter material____ t - Depth of filter material------�� __________Total -length_________r__ ----------------------- Seepage _____'______________ rSeepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to.nearest lot line______--___-___-_ I ❑ Number of pits----------------------Lining material-------------------.---Size: Diameter-----------------------_Depth----:----------------------------- Cesspool: --------------- -- ----Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- Size: Diameter__--� ::-- _ "= P "'" '""' _��..r LlquidsCapa�ity 9ais: 1 �-- _De th -____-- Privy: Distance from nearest well------------------------------------------------- from nearest building________________________________________- ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------�---------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------------------�` - - --------------•---------------------------------------------•_---------- ---------------------------------- --------------------------------------------------------------------------------------------------------- I here6y 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 aiid regulations of the San Joaquin Local Health District. (Signed)----------- ------------- - ------------------------------------------------------------------------------------------------------------------------------ Owner and/or Contractor B :---'"` i�/.a tecta--.-------- - Title v Y �� -[ )---------------------------------------------------------------- (Plot plan, showing size of I ,'Ideation o stem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY------ -------I--------------------------------------------- DATE---------- 3 5`� -_ ---- REVIEWEDBY-------------------------------------------------------------------------- -------------------------------------------------- DATE_ ----------------------------------- BUILDING PERMIT ISSUED------- ------------------,-------------------------------: :----;---------------------------------- DATE-------------------- ` ---------- _ v01 . ___.Alterations and/or recommendations:_________ ------- --- --.----•------------------------------------------------------------- ------------------------------------------------------ t `' t ------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- --- -- ---- -- - ------------------------ ,�--� FINAL INSPECTION BY--------------- ---- Date------------------- - --- -- �' � ��-- ----- = --------��------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Streef 132 Sycamore Street 814 North "C" Street . Stockton, California Lodi, California Manteca, California Tracy, California ES-9----2M 8-51 Revised W-2100