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r V !! APPLICATION FOR SANITATION PERMIT Permit No. ._�O_d.:............ (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 Ordinance No. 549. JOB ADDRESS AND OCATION /----�-D- -------sip ' Owner's.Name---�-- ---=-• --- -------=-•---';;-- ------ - ::---- --------------- -------------------------- Phone--------------------------------•--- Address-------5.1•x•-• - - --------- - -- ---- -----------=- ----------------------•----•---•------------------•----- =-- ---• -- -- --------- Contractor's Name----- ----- ------ ------------------- --- '�.°•"�,�-� Phone.�__ Installation will serve: Residencepartment-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J___ Number of bedrooms __-Number of baths'I----- Lat size __________________ Water Supply: Public"system' �ommunity'system ❑ Private ❑ Depth to Water Table .44�-•ft.- Character of soil to a depth of 3 feet: ''Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay ❑ Adobe Hardpan ❑ Previous Application Mader Yes ❑ No 94-' New Construction: Yes [ o ❑ ' r TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted.-if public sewer is available within 200 feet.) - w.. Septi Tank: Distance fromtnea x N r p ...a � P P rest well__�_�._____Dist�nca`from foundation._.__�__i�.�.�_.Mat real---_��__u_"►''�________________________._. No. of.compartments--------2—------------Size_ -- ---k.q-----Liquid. depth__!r~ L__---._-----='Capacity--. _ Disposal Field: Distance from-nearest- well-1-16. from fou ndation=__,�_�_�___._Distance to nearest lot line___��_'_... Number of lines---- - �, _�y_ 'Length` of each line---- p ---------------Width.of trench---- - - -------------------- Type of filter material____-__ .- !Depth of filter materia- _ '____Total length_-______-3_0-------------------------- I ° Seep ge Pit: Distance to .nearest well__[-_�_.____--____Distance om fo datar,, -__. �.._.__ ____.Distance to nearest'lot line_________ 'Number of pits.__.__t______________Lining material._:,::;; Size.: Diameter__Xg__...*_____Depth_.'._a f :. - -------------------- Cesspool: Distance from nearest:well_________________Distance from foundat on--------------------Lining material----------------------------------- El .__,_.._.__,._____________________❑ Size: Diameter_-------`- F-- ----De th---------------------- ----------------- -- Li aid Ca acitr - als. 0 r I - L Privy:: Distance from nearest well_____._.___- -------------------_^-_ _- Distance from nearest building______-__.__---_-_._-.-..-.___________._. ❑ *-rte Distance to nearest lot line' - "n r - - ----- ------- - --- Remodeling and/or repairing (describe):-------- ------- '' --: " ----------------------------- fxi :. . . 1 - - ----------- -------------------------- -------- # , i •--------------• -----------------------, i---...----------=---•------------ ----------------------•---------=--------••.--------- ••--------•-•---------------- 1 __________________ ______________________________________________ _ _________________________________________________-------------------------------------------------- .. _ _ __ __ ___ _ -..:., , llhereby certify thai't -•-have prepared this application-and that the work will•be-done in accordance with San Joaquin-County ordinances, State laws, and ales and regulations of the San Joaquin Local Health District. , t (Signed) - - = 4/i,." -,: 1<fl r Contractor) - i y:--- ' f '° ! '""---'-------------------------------=-------------------=(Title)-- - •-------- •-,--•------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). j F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------ -------..--------- DATE--------- ....--: '---------- REVIEWEDBY--------- ----------------------------- -�--- �=------ ----------------------------------------------- DATE----------- ------------4�: PERMIT ISSUED--------------------- ----=------- __Iv- --------- ---------r-- ---•-------- ------ DATE----- ---------------- - -------J_J --#--------- , . Alterations and/or recommendations:---- .----- ---- --------------------•---•-----•-.- --------- -------------------- ----- -------------: -------- 11 • ------------------------------------------------------ --- ------- ------'"I-".'-- ------ - -----------"------------F--------------"----------. . -- •--- - •-------•• :;-----------------.. ------------------------ -------------• --------------••---------:-----•----------------------------- = #, : -------------------------- --------•--------._.-__-------•---•-----------------•--•---------------------------------------=-------------- ----------- - •-•--•------- t i. J _ .�_ . .F.. ,-Date.._. r: , FINAL- INSPECTION-BY_____ ____________ 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 U-9-2M Revised W-2160