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APPLICATION FOR SANITATION PERMIT Permit No. .a'r (Complete in Duplicate) Date Issued !'_E'--r"-'. 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 o. 549. `- 3Ij 8 a ------- JOB ADDRESS AND L ION --------------- ------- -- " --- Phone F Owner's Name------------ Address -_-- --- -------------- F Owner's --------------------•-------------------•-------- - ---------- - - ---- - � ��------ - --- -------•-------••----------------------- Phone------------------- -------•------- Contractor's Name---------------------------- ------------- - Commercial Trailer Court ❑ Motel Other ❑ Installation will serve: Residence Apartment House ❑ ❑ f bedrooms c Number o baths ----1--- Lot size --------•-- {�-C- -------------•- Number of living units. __.1___ Number of bedro - I•c system Community system ❑ private Depth to Water Table /Oft. Water Supply: Pub i y ❑ Character of soil to a depth of 3 feet: Sand Gravel ElSandy Loam ❑ Cl a Loam E] Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No PNew Construction: Yes ❑ No VN TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Distan�j from fou tion-_�o----------Materiel----- - ..---- -- 5eptic nk: Distance from nearest well_ �j �/ y Qw -.Size._ J /i�" - Liquid depth Capacity I No. of compartments__... __-._-�j. -- - -- i Disposa field: Distance from nearest weiL.._4,T.l.r--Distance from foundation.--l�---------Distance to'nearest I t;ine-----_--5--. Number of lines------- - ength of each line- ~- q-----Width of trench--------- ----- -------------- e th of filter material-------��-------.Total length--------1- Type of filter material---- _�. - --- - P Seepage Pit: Distance to nearest well-----------------------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.---_-------__..._-.----..._-------. ❑ 5ize: Diameter--------------------------------------Death---------------------- - -------- -------- ._-_.Liquid Capacity----------------- ---- ----gals. Privy: Distance from nearest well-------------------------. ----------------------Distance from nearest building- ------------------------------------- - F1 Distance to nearest lot line__.................................................... ------------------------- ------------------------------------------------------------- Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------•------------------- --------------------------------- 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 San Joaquin Local Health District. _ ------------------------------------------------------ and/or Contractor) ------------ [Signed}------ 1l BY:------ •-•--- ----��-------- ------------------------+f� -�-------(Title)--------------------------- ---------- - ---- ------------- BY: ---------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, e1c:;1',c,:,an be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - ------------------ ------ DATE-- - 1 DATE-----------`---------------------- REVIEWED BY ------------------- -- --------- �----- •--------- ------ DATE._..-----------------'---------------------------------------- BUILDING ---- ------ -- ------------- --------- BUILDING PERMIT ISSUED-------------•-------•-------------------- ----- - f - z-------------01-- ------ ---------- -------`�1-- �•----_-=- --------------------------- Alterations and/or recommenda#ions: F..- = '---•----------••-----•----------- ------------ ---------- ----------------- --------------------------- Date---- -------------- ------------------------- -------------------- --------------- FINAL INSPECTION BY------------------------ ------ SAN JOAQUIN LOCAL HEALTH DISTRICT \ 1• } 1 k i y ) , i 814 North "C" Street 300 West OA`S#rest " 132 sycamore Street ' 130 South American Street TracyCalifornia Stockton, California Lodi, California Manteca, California y' FS-9-2M 10-52 Revised W-2100