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-C, I APPLICATION FOR SANITATION PERMIT Permit No. __..5�4.0-. (Complete in Duplicate) Date Issued Applica4ion 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. JOB ADDRESS AND LOCATION,--- -I�--- __- ---------------C .. ------------------------------------ Owner's Name-- ----� ✓ ------------------------------------------ cllr_ ------Q-_ '---- _ __ �.- ------- ---- -�-- _41 y� - ----- - ---------- ---------- ---------- Phone ----•---------------•--------------- Address '--„F.r ,l�J -� �'Yt � _ /LT. __Y �• c� -------------- ---------� 7 -- ---6- Contractor's Name------ Q_rl._ .ali_ --- -�1-- ------ ---- Phone ------•-------- Installation will serve: Residence ❑ partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms -------- Number of baths -------- Lot size ---------------------------------- ater Supply: Public system ❑ Community system p 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 ❑ New Construction: Yes ❑ No [❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_'�""�” Dista nce�from�foundafion_-_- - -------.Material__ ------ No. of compartments_--------------------"Size_-- .-- -- ,x--c _Lrquid depth_A-_- ------------ -----Capacity-- Distance Field; Distance from nearest well__r�......Distance from foundation------A�--------Distance to nearest lot fine. Number it lines___________ __ _ ___,_pp��_- Length of each line--------R _- Width of trench_____-r?----------------_-_ Type of filter material___&tom,__-- _De th of filter material__ ? p --- ----- Totaf length------��"'f------------------ Seepage Pit: Distance to nearest weli-�7 �"__Distance f m f fu tion____ -----Distance to nearest lot line__-_�� Number of pits-----/------------Lining material__ ize: Diameter--- ----Dept'r,_------ ,_�--�------------- Cesspool: Distance from nearest well-----------------Distance from foundation---____--____----_ Lining material___________---------------------------Size: Diameter---- --------- -------------------Depth----------------------------------------------------Liquid Capacity---------------- ------gals. Privy: Distance from nearest well----_-------------------------------------------Distance from nearesr building------------------------------___--.- - ❑ Distance to nearest lot line---------------___ -Y - -} - Remodeling and/or repairing (describe)- --------------------------------- ------------------------ ------------------------•--------------------- -----------------------,-------------------------------------- --------------•------------------------------------------- ------------- - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to aws d rules regulations of San Joaquin Local Health District. (Signed)_.- �� ` ' ------, Owner and/or Contractor) By:----------------------------------------------•----- - - - - -- --- --- Title (Pl - - - - - - - - - - --- -- - - -------------------------------------- ----- ot p an, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- ------ --- -------------------------------------------------------------- DATE--------- ' t� - REVIEWED BY----------------------------------------- ------- DATE--- �- -` BUILDING PERMIT ISSUED ------------------------- ------- ------------------------------------------------------------------ DATE-------- --------------- ------------------------- Alterations and/or recommendations___________ __�___ - ------------------------------------- ---- ------------"--:---------- ------------- FINAL INSPECTION BY:. ` --- Date- --- ---------- -------'___7------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef ' Stockton, California Lodi, California Manteca, California Tracy, California } . ES-9--2M ; Revised W-2100