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APPLICATION FOR SANITATION PERMIT n Permit NO. ......... �y /6``T �-S yS -:� —; (Complete in Duplicate) � _� Date Issued _Q__ _7. '_SY Application is hereby made to the San Joaquin Local Health District for a permit to nstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------4,-,l---------- - --------------- Owner's ---------- --Owner's Name. - —!_, _ "------------ ----------- ----------------------- Phone----------.----------------------- Address_ ---------------_ _ - �' '� q �. Y =,-- ----- - -- Contractor's Name-•-------------' �,......� = - � �, -' �'-°� ' =` ----- Phone---, Installation will serve: Residence ',Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /--- Number of bedrooms __-r*'__ Number of baths /____ Lot size Water Supply: Public system . (] Community system.❑ ,Private ❑ ,Depth to Water Table`) ft. Character of soil to a}depth of 3 feet: Sanr/Gravel ❑ Sandy Loa Os-C a Loam ❑ Clay ❑ Adobe [j Hardpan ❑ Previous Application Made: Yes No IV New Construction: Yes [A No 0 * TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sew "r-is available within 200 feet.) I I R Septic Tank: __ _ ' __ istanc , s Distance from nearest well _ _ e fro M1 founclation--7-U--- ------Material___________'__Ele --i -___-___________________________. ,~No. of compartments_ i ---------------f- ______________Liquid depth--------------------------Caacit /��{ Disposal Fie]d: Distance from nearest,welA�6Z4_;stance from foundation__!__[{__-----------Distance to nearest lot.line.__ ~____ Number-of lines—-,(�'_�'�__- _,_ __ Length of each line------ f______________Wldth of trench___ �r x a P • ' g Type of filter material _. ---_ __4De th of fill aterial*-j-_.c'__________Total length _'� ?___ ___ _--------- Seepage ________ I> p g f Di nce fdom foundafi .- _ See a e Pit: Distance to nearest well _: :.._._..Distance to nearest lot line____ __ _ ❑ Number of-pits '- _-- --.__Lining m erial��1 _? � Sa ;2 . Depth------- _-------- ' Cesspool: ' Distance°from nearest well----------------- istance from foundati n--------------------Lining material-------------------------------------- El Size: Diameter - --- --- th •----------------- ----------------Liquid Capacity------ ---------------------gals. i Privy: Distance from nearest well_____________________________________________ istance from nearest building------------------------------------------ El Distance.to nearest lot line ----------- --------- -------------------•-----------..-------•----------------------- --- Remodeling and/or repairing {describe)---------- -- -- t-----t----/#--.--- -rpt`'_ ------ --:--•-•-----------------------------•---- _ ----•--------------------•-•••---•-- =- ------i------- = --------------------------------------------• -----------• -• -- # 1 -, ---------------•-•-------------------• ---- --------- i - h'at I have re ared this -- lica}ion an------------------ -•- -----------------•---------------------------------------------------------------------------- I hereby certify t i p p pp c1 that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and egulations of the Sa ' Joaquin Local"'He Ith District. (Signed).------=-- '✓' ? r '- # -"�'- =ems'! =(Owner nd/orntractor) p/� By:-------------- ( '` '="'=-- -------------------------.-----------------------------------------(Title)--- ' ' (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y � FOR DEPARTMENT USE ONLY APPLICATION ACCT PTED BY-='------ --------------- --- ---- ----- -------------------------------- DATE-----------------f -Y__ _-�_ _ •__ _____ - - REVIEWED BY-------- ; ---------- -- -------- --------------------------------------- DATE------------- --------------- BUILDING PERMIT ISSUED------------------------- -----------------------------------------------------------------.- ------ DATE = Alterationsand/or recommendatians:' ----------------------------- ----------------------------- ,---- ----- ---------------------------------------------------=-------------------- ---------------- ------------ -------------------- I ------------------------------------------------------------------------------ ------------------------------------- ------------------- --------------------------------------------------------------=-------------------- ------------------------------------------ r FINAL INSPECTION BY_____________ f Date ' SAN JOAQUIN LOCAL HEALTH DISTRICT .r 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES---9--2M, 8-51 Revised W-2100