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APPLICATION FOR SANITATION PERMIT Permi No. � -- . t (Complete in Duplicate) 3 .- Date Issued ___.�#'�/ - 401 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 Ordi nce No. 549. JOB ADDRES D LO TI N_S;�P__ --------- - --------- ------ ----- 4V---------------------------------------------------------------------------- Owner's Name-------------- -- ---- -------------------- - Phone.Z_— . _0__j--- ---- Address_.:1---�---7-�-J .... -----• •------ ---•-- ---------------•--•-----...... . Contractor's Name--- ------ •-------- ----------- _.Q------------------------------- Phone----•---•--•------•----•----------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] MPfel E] Other E]Number of living,units: _/Community umber of bedrooms --&- Number of baths _1_.__ Lot size _Y____ __r!_ Q_1___•______-.__-____:____ Water Supply: Publicrsystem system'❑ Private 0' Depth td-Wafer Table -------- -ft. _ Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam / Clay Loam E] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes E] No Sand Construction: Yes [> No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well_________________Distance from foundation_-_-------------.__Material------------------.-------------------..--------- No. _____--.N1 of compartments-------------------r------Size-----1---------------------------Liquid depth.------ -----------------.-Capacity------ ------�/---- , Disposal Distance from nearest-well -` '�isfance4rom foundation_-JO- /T�'�'Clistance to nearest lot i + r �� Number a�i lines__________ ______ ____________ _Length of each line___________ f_ Width of trench _ r________----------------- Type _____Type of filter mater _-! Depth of filter material----__.� Total length-__- il________________/____________ �� stanc yromcl y .� i f � -- Seepage Pit Distance to nearest well__________ istance from foundation___,_,`�'....___.Distan�e to nearest lo# line__-______--._ Number of pits______ ____________Limng material _C__ _�._'�:f•� Size: Diameter_._____A�. ______-Deptn_..;r.�___ -__..__-_-_ R 1 1 _ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------.-___.__.__.______.. ❑ Sizc: Diameter----------------------------------------Depth-----------------`---:------------ ---------------Liquid Capacity- --------------------------galsr ' 1! Privy: Distance from nearest well--------_________-_____...______.__________i__Distance from nearest building---------------------------------------.-. ❑ Distance to nearest lot line--------------------------------------------------- ----------- ------------------------------------------------------- ------------------- ��y pRemodelingand/or re airing --------------'�!+1----------------•��------------------------------------ �---------•------------=�•---'•�-_�,_-•_-_.._._. I ,- F %�- --�'�--------- '�.� -- r_ ► - — -----+_ --------------------------------------• ---- �< " - --------------------------------------- -------" '�-------------------._ . r--.� ==- -- -------------=-------------------------------------------------------------------------- ----- -------------- I I hereby certify th�.t ll-^have-prepared-f hisrapplication and that-the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San oaquin Local. Health District. -- - -- - --R�•)------------------------ (Signed)..__4�,� ...- ; ti -- (Owner and/or Contractor) L(Title) BY: ---------------------•---:------•-----`-- ---------------------------•- ----------------------------------------------------------- ---- (Piot plan, showing size of lot, location of system n-relati_on,.fo'wells, buildings, etc., can be placed on reverse side). FOR DEPAARTM NT USE ONLY APPLICATION ACCEPTED BYC --------------------`------------------t DATE' --- - --- - REVIEWED BY -:= V' -. -�-""`� ` -_':.:w.:-- #--R-F__ __ D.AT,. - -------- = BUILDING PERMIT ISSUED ------ ----- ------------------------ - - --------- -- ---•--- -------------- Alterations and/or recommendations:---------------------------- ----•------------- ----••---••--------•----•--------•-------------•--------------••- r'`Rf ."' ----------- •-•------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------•--=------ ••-----------•-•---------------------- ----•----- •-------•------•-------•--••------------•-----------------------•---• -------------------------------------------------------------------------------•-•---- ------------•--------------.------------------..----- ----------------------------------------------•---------------•------------------------------------------------------------------------------- ---------------------------------------------- ------•------------------------ ----------•-------------------------------------------------------------------------------------------- ------------- -----------------•-----------------------------------•-- -------------------------------------------- FINAL INSPECTION BY:- ------- -✓r------ -------------------------- Date--------- ------------- } SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfree-f 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100