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APPLICATION FOR SANITATION PERMIT ,` °Permit No. .�� (Complete in Duplicate) /O Ss Data Issued .---- !Applica+ion is hereby made to"the San}Joaquin Local Health District for a permit to construct and install the work herein des Zbed. ,:This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------- ----------------••--------------------------------------- Owner's Name-------. ------•--- ---------------------------------------------- --------- ------- Phone / /-�1 Address-------- `0Z" - --- - --- --------------------------------------------------------------------------------------------------------- ---- ---------------- Contractor's Name--. y- 1 �� --�---- Phone 'j/----�a__-' 6 -------------------------------------------- ----------- ---------------------- Installation will serve:"ResidelnceApar+ment House ❑ Commercial ❑ Trailer Court ❑ Motel P Other ❑ Number of living units: -�_-- Number of bedrooms .-- --- Number of baths _-.----- Lot size _--------- ---- ---- ---------- ----- --- Water Supply Public'system�� Comunity system"E] -Private ❑ 'Depth'to Water Table ft. Character of soil to a depth sof 3 feet: Sand [-] Gravel [-] Sandy Loam El Clay Loam E] Clay ❑ Adobe ID Hardpan ❑ Previous Application Made: ;Yes ❑ No P New Construction: Yes ;Z No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weIL�4_Y-Distance from foundation_----1-_---.-.--.Material_---___________________-_--------_.__.__--__... ` No,of�corn artments_____ _ - .--------------- r r / / p -aSizes�Xya.X-=S---------Liquid depth---�lz------------Capacity--- ------ Disposal Field: Distance from nearest well-&A#Distance from foundation------------- Distance to nearest lot line_--_--..-------. Number of lines-_;_!-__-__-�.---- -------Length of each line--------�s---_---___ __Width of trench-.-�y"---------------------- Type or filter material-S _/ o-c%------Depth of filter material ---IX..............Total length------75------------------------------ Seepage" Pit: Distance ;to nearest well NQ--V 41---Distance from fo ndation__--�5�-_---.(distance to nearest lot line---�d�..-- ag of pits------- [lYt.(`- -----------Lining material- Size: Diameter-----3 Number -6- :-------Depth--- ----------.------ Cesspool: Distancellfrom nearest well-----------------Distance from foundation-------------------.Lining material--.--------.-----.-_.___------.--.---. Q ❑ Size: Diameter------------------------------------- Depth-----------------`---------------------------------Liquid Capacity----------------------------gals. y: Srom nearest well--- - ^-�---�' __Distance from nearest building i Priv istance'.', ------ ------------------------------------------ • (] Distance '�to nearest lot line---------------------------------------------------------------------- ------------- -----`- I Remodeling and/or repairing (describe): == -----------------------------•-- -------------------------------•------------•---• f :!l .. w. --- ---------------------------- ---- -- ------------------------------------- -- -------- t --------------------------------- --------------- = --------- k ----------- -------------------------------------------------------------------------------------- -------------- I hereby certify that I have prepared this application and that th'e work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin-Local Health District. (Signed) ca-" /L-6 ------------- --------------------------------------- ---- -------------_--- Owner and/or Contractor --- - --- - ---- (Plot plan, showing size of lot, Iota}eon of system in relation to wells, buildings, etc., can be placed on reverse side). it FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED II BY----------------- ----------------------------------- lDATE----------- ----------- REVIEWEDBY-- -------------------- ------------------------------ -----------------------------------------. DATE------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------------------. Alterations and/or recommendations-------- ----------------------------------------------------------------------------------------•--------•--------------------•------------------------------- ' !l ;I ------------------------------------------- ----------1-•----•----------------------------------------------------•---------------------------------------------- •--- -------------•---•---•----------- ------------------- -------------------------------I------ ---------------------------------------------•---•---•-- - --------�---------•--------•-•-----------•----•-------------------------------------•----------------------------------------••-----------•-----------------•------------------------ II ------------------------------------------------- ------------ -------- ---------------------------------------------------- ----------- ---- ----------- - FINAL INSPECTION BY:J±-------- ------- --------------- Date . ------------------------ -------- - ---------------- jl SAN JOAQUIN_LOCAL HEALTH DISTRICT r 130 South American Street 1300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California ES-9-2M 0-52 Revised W-2100 p 0 x !