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/ { APPLICATION FOR SANITATION PERMIT Permit No. ._J�._f (Complete in Duplicate) Dtfe Issued`S �f '[,l Applical-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. 4 r �Jm JOBADDRESS AND LOCATION....... - -:--- -( _ -----------------------------------------------------------------------------------------------•------------ Owner's Name r ------•------- --------- -----------------`- ----- Address --- Phone - Address----- ------ ---------------------------------------------- Contractor's -------------------------------------•------Contractor's Name..-------- -T ----- ------- -------• •------------'--- Phone -4�? Installation will serve: Residencepartment House Ll Commercial ElTrailer Court E] Motel Other ❑ l / Number of living 'units: _/____ Number of bedrooms ________ Number of baths --- --- Lot size Water Supply: Public system❑ Community system ❑" Private Depth to Water Table /S ft. ? Character of soil to a depth of 3•feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ®---H-ardpan ❑ Previous Application Made: Yes ❑ No 2�-- New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:- (No PECIFICATIONS:(No septic.tank or cesspool permitted if public sewer is available within 200 feet.) e�ati Tank: Distance from nearest well----------------:Distance from foundation____.___----_--_.__.Material-------.____.-_-----_______:___-__._-___________- No. of compartments---- Size--------------- ----- ----Liquid depth---------------- ---------Capacity------ ---------------- Disposal ield: Distance from.nearest well.�? _..-:_..!Distance from foundation__��__._______-Distance to nearest lot line___`-------- Number _--- V� ' Number ofiines--------/-----------------------Length of each line-------74-----------°-----Width of trench.--- -y_---------------------- Type of filter material-4_R _:_..._Depth of filter material___:/e_7-- -_-_Total length______7�_--__________________________ Seepage Pit: ' Distance to nearest well- .7--------________Distance from foundation___`...:... ._._.Distance to nearest lot line-------___.______ ❑ Number`of pits.----_-'---------------Lining material------------------------Size: Diameter------------------------Depth---------------------------------- Cesspool: Distance from nearest well-----------------Distance from founds+ion--------------------Lining material__..____---_---.___-.-_____________- ❑ �..- Size: Diameter----------------------------- �FDepth _ __ '---------------------- � Capacity ------------------------=---gals. Privy- Distancefrom nearest-well.._._____._____ -- __________ _ __ _ .._Distance from nearest building.-___._______.__________________._._.____- ❑ -Distance'to nearest,lot line" - - - - ----------------------------------------'------=--- ----------- --------------------------------------------------------- Remodeling and/or repairing (describe)__________________ ---•------------------•-------------------------------------------------=------------------------------------•---------•----- -------------------------------------- -----------=---.._..---------------------•----- ---------------------------------------------------- -------------------------------------------------------------_------_----------------------------•-----•------------------ ---------.-.--------------------------------- -------------•---•----------------- ------------------------------A------__--------------._..--------------------------------------------------------------------------------------------- ---------------- --•------- I hereby certify that,l 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. (Signed) -0'° '-Lz` `.R------- --- -------------•--- .'--- Owner and/or Contractor) By:---------------- 1C-e-Q--Irk- -- .. ----_---------------------------•-------------------------------(Title)- -------- --a--'-=�--------------- (Plot plan, showing size of lot, lacatio f sys+em in relafion-to wells, buildings, etc., can be placed on reverse side). F FOR-DEPARTMENT USE ONLY K x 4 APPLICATION ACCEPTED BY --------- -- ------- DATE------ 4 - --------------- REV.fEWED BY__ 4.-- ------- --------- --- ------------------------------------------ DATE------:--------- ------•---- BUILDlNG PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------ Alterations and/or recommendations:- - ------ ---------------------------------=---------------------------F-------------------•-------------•--------------------------------- ----------------------------------1------------------------------------- ----------•--------------------------------------------- '-----------------•------------------- - ---------------------------------------------------------;--------------------_---•---..-------------------------------------•--- ---------- f ! --------------------------------------=-------------------------------------------------------------------------------------------------------------------------------------•----••------------------------ ----------------- ----------- - --------- ------ ------ ----- ------..------------------------------------------------------- ------- FINAL INSPECTION BY:= =- =----------------- -- _ .� Date c "" fS -`------------------------------------- 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 E5---9-2M Revised W-2100