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- APPLICATION FOR SANITATION PERMIT Permit N000v4:11. (Complete in Duplicate) Date IssuedL3� Applica-1-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. S / JOB ADDRESS AND LO TION--:/Q ------l-/ --------- ---- -------------------- --- Owners Name --•-....4 - - .- •` -------•----------------------------------------------------- ---------- -- Phone--,;— Address.....-_C7,5-6 `- ----------------------------•--... ' Contractor's Name `_---------------------------- 1 --7: -----11---. Phone.v�------------------ Contractor's 6- Insfallation will serve: ',Residence 2"'Apartment`Hous'e❑- Commercial-❑ "Trailer C;64 E] Motel ❑ Other ❑ Number of living units: _A;?— Number of bedrooms _ -- Number of baths __a"_ Lot size --------- ------------------------------------------ Water Supply: -Public system Community system [I Private ❑ Depth to Water Table 3X- Water Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑i Clay ❑ Adobe [Hardpan ❑ Previous Application Made: Yes ❑ No [i-"Now Construction: Yes Pffo"No ❑ TYPE OF INSTALLATION AND SPEC IFICATIONsS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest well______________._-_Distance from foundation-------____-----_-Material------------------------------------------------ . 13 .. • No. of compartments ----------- -----------Size-------------------------------Liquid depth---�----------------------Capacity-----------------------� sppsalield: Distance from nearest wefi---.---_____-.._Distance from foundation__-----------------Distance to nearest lot line----------------- t Number of lines-----------I ------------------------Length of each line--------------.-'-------------Width of trench..-.------------------------------- 'Type ------------------------------ 'Type of filter material------------------------Depth of filter material-----------------------Total length----------------------------------.-_-_--- Seepage Pit: Distance to nearest well..AIWLfi—___Distance n--__f---------- Distance to lot iine__ --------- Number _.-- Distance from fo ndatio _ --_ Numberofpits ------ '---------Lining material__ Size: Diameter----3.0' _----Depth---PS ,------------------- Cesspool: Distance frorrV nearest well-----------------Distance from foundation--------------------Lining material--.--.--_-_-_-.----------_,---._---_- ' _.. .Size: Diameter_----- =---- ---=`De`th-` -------------------------- Li uid Capacity Privy: Distance from nearest well---------------r_._-------------------------------Distance from nearest building--_-------.--.-----_----_-------.-. ❑ Distance to nearest lot line-------------------,- ` �° Remodeling, and/or repairing (describe) ! ------------------_____.------._. T - -..-.. - �---------------------•-------------••------------------------------• --- ----------- - -----------•-------------------------•----------------•------•---------=------------•--------------------`----------------•--=--•-•--•------------------------------------------------------------------------------------ I ----------------------------------------------•--------------•--...----- ----•-------.._.-.._..-----------------•------------------------------- - ----- --•----•------•----------------•--------------------------------------- t I. ----------------- ---•-•--------------•------------------------------------•---------------•--------------------•-•---------------- 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 Hea�istrict. .. - I I I (Signed)------ -----------------------------------�..-------------------.... Owner and/.or Contractor) :_ • ' _ '..'n ` ' By:-------- �� i�---- �--------�------- -�.-.---------(Title)---------- ----------------------------------------------------- ....... (Plot plan, showing size of lot, locati n of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ---=---------- -----------------------------> --------------------------------- DATE-------------17t----2-----:5r-V•----------------- REVIEWEDBY--------------------------------- ----------- -------------------------------------------------------------------------------- DATE---------------•--•---------------------------------------- BUILDINGPERMITISSUED-------------------------------------------------------------------- -------------------------------- DATE-------------------------------- Alterationsand/or recommendations------ ------------------------- ----- - - -----------------------------------------.--------------------------------------------------------------------------- --------------------------------------------------------------------- a -----•-----------------•--------------•---------------------•-------------------------------------------- -----•-------------------------------------------• ------------------------------------•------------------------- ----------•-------------------------------- ----------------------------------------------- ...... -----------------•-•-------------------------•-- ------------------------------------------ FINAL INSPECTION BY:, - ------------------------------------------ Date----------�---- ----� - - -• -- -•• •-------- � . 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 FS-9-1m ' RRv;I Arl W-7100