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APPLICATION FOR SANITATION PERMIT jPermit No. _.- 3 { (Complete in Duplicate) ( 1 = ` ------ Application is herebymade to the San Joaquin Local Health Distri Date Issued .-7�� This application is made in compliance with County Ordinance NoC549r a permit to construct and install the work herein described. JOB ADDRESS AND LOCATIO Owner's Name---------- 5 #40# S-4-4 . --------------------------------------- -;0-------- = Address Phone Contractor's Name -----•------------------------•- ne Installation will serve: Residence Aparfiment House --------------•------"----------------------- Phone -------------• Number of Iivin units: - s E] Commercial ❑ Trailer Court E] ' Motel g f-- Number of bedrooms - — ❑ Other E]Number of baths -------- Lot size ----0-0-- Water Supply: Public system ❑ Communitys system ❑ Private ❑ Depth to Water Table .----___ ft. Character of soil to a depth of 3 feet: Sand ; ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction. Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: E] (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well---------------- Distance from foundation_----- ❑ No. of compartments-------- -- -- t-- Material------------------------------- Size ---.Liquid depth - -Capacity---- ---- ------ isposaf Field: Distance from nearest weil-----------------Distance from foundation--------------------Distance to nearest lot line-----_--.---_-_-- ❑ Number of lines--` ---------------- th Type or` fAter material----- ---- ------ ---_--Depthhoff filter,mraterial------------------ ---_otal length �'ch:---- --.- --_--__"_-----_ Seepage Pit: Distance to nearest well--------------- istance from foundation--------------------Distance to nearest fot line-_-___--_-_---"-- ❑ Number of pits----?----------------Lining material------------ ------__.Size: Diameter--_.------- Cesspool: Distance from nearest well_______________ _Distance from foundation-------------------- �---Depth._---"-._--_____ ❑ Size: Diameter--------•--- -- Lining material----- ---Depth- ------- -- ----- - --- --� - -- ------- Priv Liquid Capacity__----------------- t Y Distance from nearest well... -------gals. ------ -------------- ------- --- - ----- -- �/ �------YA=P^-- --__--Distance from nearest building 0 Distance to nearest lot line A � g------,��_--_---- --- emodeling and/or repairing (describe):-_-__---_ - . -------------------------------------------------•--------------------------------------------------------------------------------------------------- D ----------------------------------- ---------------------•----------------------••--•--------------------------------------------------•------------------------------------------ ---- ------ -- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun} ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. . t, Y (Signed)------ - .. ---------------------------------------------------•------------------ BY:---------•-------- = (Owner and/or Contractor) (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can lie ----"--------------------------------------(Title)---------------------------------placed on reverse side). FOR EPARTMENT USE ONLY APPLICATION ACCEPTED BY----. .-- _- -. REVIEWED BY------------------------------------- l DATE - -_ -- ----- 4 -------------- BUILDING PERMIT ISSUED DATE ------ -- , ---- A aerations and/or recommendations----------- -- l-.�=.� ------ DATE --------------------------------- --------------------- ----------------- ------------- -------------------------------------------- ---------- ------------ !.' _ •--F---..-_-_---.--------•_ ---------------------------------- - - =�.--_-- ---_ ---.+ -- ------------ . -.-V-- ---- FINAL INSPECTION BY: r I , , Date---- �- ---------- �- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street b •T 300 West Oak Street : 5 Stockton, California s_ 132 Sycamore Street Lodi, California814 North "C" Street ES-4-2M io-sz Revised W-2100 Ivlenteea, California ' Tracy, California