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ti '! APPLICATION FOR SANITATION PERMIT Permit No. . ._. '"• w` �` (Complete in Duplicate) Date Issued 1 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 AND LOCATION_-_-_ ` __7.6-- Phone k Owner's Name-------------- t------ Address------_-----------• - - Contractor's Name --------------•--------..:. ' Phone----------------------------------- ' Motel [3 Other ❑ # p ❑ f Court ❑ Installation will serve: Residence Apartment House ❑�Commercial Trailer Co �o XIS � � Number of living X nits: ________ Number of bedrooms __..__-_ Number of baths -_____ Lot size ______ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table G_ ft- Water soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam ❑ Clay Loam. Clay El Adobe Hardpan E] r Previous Application Made: Yes No [�1.New Construction: Yes �;K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: l , d. (No septic tank or cesspool permitted;if public ewerls-available,within-200 feet:( 50 -Material- = l Se tic Tank: Distance from near.esr well____,. .---__Distance from foundation__.__ _ �Q a f t Size �� Q c3 -Liquid depth_: . Capacity...... No. of compartments-..._ ___� - - µ r ---------- ne Dis os� Field: Distance from nearest well:-_j_4� -- istance from foundation_____I Distance to nearest lotZli �-___. ( Number of lines---.-.n. -------------- Length of each line--------:- --- n-----.Width of trench------------------ ---- -------- d ' Total len th -------------------zp--- Type of filter material__'_ _ 4�r_. :epth of filter material________/9________ g Seepage Pit: Disyance tonearest w IIS._._. __-_.__ ___-Distance from foundation___________________Distance to nearest lot line ::__ Number of pits._ _ _Lining material-----------------------_ Size: Diameter--_-,_-.-,-----w-=<1Depth_: ---- �- I - Cess ool: Distancefrom=nearest well?=- - -- - Distal �ee from foundation--------------------Lining material__..__.. _._.: --- -- • Size: Diameter_____________ ---------------------------------------------------_Liquid Capacity___________________ gals. Privy: Ditance from ;nearest vrell._______________ _y_-____________.•------------Distance from nearest building__,__..__---_.__-____------------------.. ❑ Distance to nearest lot line----- -------- ---------------"----- -------------- ----- Remodeling and/or repairing �descfibe):_"":-"°""'_''"` "�'-- ._ -------- --- -------------- ---------- •-- ---------------------------------------II---------•----------------------------- ------------- II ------------------------"-----------------•------------=--i--------------------- ---- ---------------------------------------••-------------------------------•------------- I hereby 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 and,regulations of the Sa"nNJoaquin Local Healffi District. '� . � ---- - -----•----------------------- (0 1 er and/or Contractor) ► (Sign ed)__� ---------•--------1- --? _ --------------------------------------------------------------(Title)----------- ----- - ----------------------- ---- --------- Y� ' :9, (Plot plan, shawingtslze of lot, locatWri of-system in relation to wells, buildings. et 1, can be placed on reverse side). �i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.---- - ------------- - DATE _._. ----------------------- ---------------------- '-------------. DATE = B•lJILD NG PERMIT ISSUED. r ----- DATE---------------------- Alterations and/or,,,porrVmendations: - ------- ---------------- -------------------------- 1 .- • ..---"•----------------------------------------------------------•---- ------•----------- 11 - y -------------- `� _ ------- -------- ----- - ------------ ---------------------- ----- ------- --------------------- ----------/- I -------------------- Date......../ �� ----------------------------- FINAL INSPECTION BY:_... _______.. ------------ - SAN JOAQUIN LOCAL HEALTH DISTRICT + 1 1 130 South American Street 11 300 West Oak Streeter. 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California t� E5-9-2M 10-52 Revised W-2100