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APPLICATION FOR SANITATION PERMIT Permit No. __...` -10 (Complete in Duplicate) Date Issued stall the work herein described. Application is hereby ade to the San Joaquin Local Health District for a permit to construct and in : This application is made in compliance Iwith County Ordinance No. 549.. C `92 3 3 .Sd U 7— Q G G V ------------------ JOB ADDRESS AND LOCATION--------------------- ---------•------------- ------------- Owner's Name __ = wt-_-------+ Phone -------- .,� Address1 '� C --- ----- --------- •------------- •----------------------- -------------- Contractor's Name_. 1-------------------------------- ` Phone----------------------------------- - Installation will serve: Residence K' Apartment House�'0 Commercial ❑ Trailer Court V Motel ❑ Other ❑ I i / . 7` ...!,3 O------------------ Number of bedrooms -+ - Number of baths .)_-___ Lot size - Number of living units: ---I_ S t ..�.e .� � Water Supply: Public system x Community system ❑ Private ❑•. Depth to Water Table__.__"- ft. Character of soil to a depth of 3 feet: Sand ❑ Grad ❑ Sandy Loam ❑ Clay Loam ❑ #'Clay ❑ Adobe„ ' Hardpan ❑ I Previous Application Made: Yes ❑ {No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: --� -- (No septic tank}or cessgoolI..'pei:rnitted if public sewer is available within 200 feet.] Sept c Tank: Distance �rom�nearesr well__=_a_-____._.DIsfianc from foundation----/_____--------_Mat a .:l--------------'------------' \ I, of comp�rtmenfs � f�-Y-------`Size---.-__�_q_-.�_ Liquid depth - Capacity %X I E I Disposal Field: Distance from nearest well----_�_-_Disitancefrom foundation_____ - Distance to Barest lot line__�r -_..._ W Number of lines Le �gt""h"'6f each line ------� ---•----.Width of trench-----------Z.µ -------.- w : � ---- fh of filter material -_Total length___._______________ _ Type of filter material-_� �✓�.�Dep., „ f Seepage Pit: Distance to nearest well____________________Distance from foundation--------------------Distance to nearest lot line__._"____.______ Lining material Size: Diameter-- Depfn Number of pits___}--____-__.._ t I d :•k. Cesspool: Distance from nearest well--------__.i_--.-�Dis�ance from foundation...________.__-".Lining material_____._�_________________________. ' ❑ Size: Diameter----j----------------------- Depth ------------------- ---------------------------- Liquid4CapacitY gals. I 1 Privy: Distance from nearest well.------____-----------------�.-----------------Distance from nearest building________.-_._______-------------'------' ❑ Distance'to nearest lot line------ _ -------------------------•----- ------------------•------------------------ -------------------------- ------------- a^-- 40 ''-4- "G Remodeling and/or repairing {describe):_ ------------- f ---- ---- -- € --------------------------•------------------- --------------------------- I --------•-------------- a ---------------------------•-------------------------------------- ----------- ------------------------------------- l ------- --- ----------------- --------------------------= ----------------------------------------------------------------------------------------------------------------------•----------------------------------- ! 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 San Joaquin Local Health District. ______________(Owner and/or Contractor) (Signed)-- -- -------(Title)- = - ----------- ------ By---------------------------------------------_ - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on never�e side]. r FOR DEPARTMENT USE ONLY DATE------"- ' - APPLICATION ACCEPTED BY---- ------ - - - ------------- ------- - -- ------------------------ REVIEWEDBY-------------1-------------------------•------- - ---- --------------- --------------------- i BUILDING PERMIT ISSUED--_-------------------- ---------------------------------------------------------- DATE---------------- ------�----------------- _.." 1 Alterations and/or,recommendations:_:.:________"_.._.-------- '"""= == -- - --------- ----------------------- ----- ----- --- ------------------ ---------------------------------------------------- ---------------------------- i --------------------------•---- --------••------ -------------•--- -----•--•:•---•---•1- -----------------•------------------------ ------ ---- -----•-----•-•-•-------------------------- YI Da+e _________________________________ --- -- , - ---------FINAL INSPECTION BYc.._ SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North •'C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y ' r ES-4-21A 10-52 Revised W-2100