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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) i Date Issued A/-Q-'tS"_Z ' 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. , s JOB ADDRESS AND LOCATION-- ®---. . --- ----------- -------------- { Owner's Name------------------ --------------------- Phone --- - - --------------------------------------- - r r [ Address -�--- --- F ----------- - Contractor's Name ---- 1 � Phone 6� ± ---- Installation will serve: Residence e Apartment House ❑/ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units::,-___ Number of bedrooms __f___ Number of baths -/-___ Lot size ___ --------------------- Water Supply: Public system [Community system '❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;-'No Clay Loam E] Clay E] Adobe �ardpan L]Previous Application Made: Yes E] No �I�lew Construction: Yes ❑ " "M f TYPE OF INSTALLATION AND SPECIFICATIONS: # V (No septic tank or cesspool permi+ted if public sewer is available within 200 feet.] r r Septic Tank: Distance from nearest well_______________Distance r m foun ation__-1-4--------Material_ 4- No. of co�"Partments_______-� - Liquid de th___.'�.- -- -- Capacity---,t�-------•- Disposal Field: Distance from nearest well-----------------Distance from ---------- f dr ---------Distance to nearest lot line______ 1 Number of lines________ '_ _ Length of each line_pC1___ -------Width of trench j_ _ --___________________ __ Type of filter material __ __Depth of filter material__Z'�__.______.__Total length_____ee--------------------------- Seepage Pit: Distance to nearest welt-----------------------Distance from foundation-----------:--------Distance to nearest lot line_:______________ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-----------------_--------------- ' Cesspool: Distance from nearest well------------------Distance from foundation-------------,_-____.Lining material____=_______________________________. ❑ Size: Diameter--•-----------------------------------Depth------------ ---- ------------------------`------Liquid Capacity----------------------------gals. Privy:' Distance from nearest well-------------------------------------------------Distance from nearest building-________________________________.______- ❑ Distance to nearest lot line]Q ,t, - ------------------------------------------------------------------- -- Remodeling and/or.repairing (describe):-----. �/" "" -*)A..-- 01Z.------- --------- ,- ----------------•----------------------------------------------------------- r ' ------------------------------------------------------ a ------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------•-------_-------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County d ordinances, State laws, and rules an regulations of the San JoA uin Local Health District. � t (Signed) � __.._.Wgd_d - Y� - "�'�� __ Owner and/or Contractor Plot plan, showing of lot, location of system in relation to wells, buildings, etc. (Ti+le]---e ---------------------- By: F --------=----` ----------------------------------------------------- ( p g y g , can 6e placed on rev a side). -�- FOR DEPARTMENT USE ONLYAPPLICAT `. n '' ' ) -------------------------- DATE-----------------' i ---------------- REVIEWED BY--------------------------------------ON ACCEPTED BY .eW,, v�_"` ,�-=---=------�-=-----------------------------------�-----. DATE----�-�"--.=`� --=�``• - 4 BUILDING PERMIT ISSUED--------- r �A" -``-�,�-------"'----- ------------ DATE_- --------'------L'"..----------------- -------- ----- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------•-------------- ------------------------------------------------------------------------------------------------------------------------------------------------------•--•--------------•-------------------------=--------------------------- -------------------------------------- ---- ----------•--------------------------------------------------------------------------------------------------------=-----------•------------------------.------------------------ FINAL INSPECTION BY:----W- v Date---------- f -' ---�------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT -- 4 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street, Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 --- –