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la1 APPLICATION FOR SANITATION PERMIT P , --- -- -�.- (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for ap ermit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 49. JOB ADDRESS AND LOCATION------ �-------�-! C2- ------ ------ '' ---------------- Owner's Name-------- ------------------------- 1._/------- int- --- --------------------------- Phone-------- -7 /------------- IAddress - -------- --- ------_ _.... -------------------------------------------------- Contractor's Name---------------------------- � f r ------------ Phone------ =f�4al�j Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of baths __ ~ y Number of living units: __.�_ Number of bedrooms �_�- Lot size .___________0______r_��___ ______________________ I Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table0_12 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,K Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 7 {-. No septic tank or cesspool permitted if public sewer is available within 200 feet.) is Tank: Distance from nearest well_________________Distance from foundation--------------------Material_____________-_--__---_______________________- i �•-~�'f No. of compartments--------------------------Size-----------------------------._Liquid depth--------------------------Capacity------------•-•----- { osal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line________________ Number of lines-----------------------------------Length of each line------------------------------Width of trench--------------_-_--_-------___----_ k Type of filter material-_________ _ __________Depth of filter materia;-----------------------Total length---------------------------------------- - • �,r 6� F Seepage Pit: Distance to nearest well_-_______ _____Distanc�r m, f undation..................Dis#ante to nearest lot line__;________-__... Number of pits__________________Lining material _____ _-��_____Size: Diameter___ , _�_---Dept h___ _4__'_______:___-___ ' Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------.------ S ize: ____- Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. . Privy: Distance from nearest wells_ Distance from nearest building_________ ❑ Distance to nearest lot line-----------------------------------------------------------------••--------------------------------------------------------------------------- f p N. Remodelingand/or repairing (describe):-------------------------------------------------------------------•------------------------------------------------•-•- •----1-------- ----•- ---------------------------------------------------------------------•------1-1- ----1-1---•------------------------------------------------••-•---•-------------••------------------.-------•---------------•------------------------- t ------------------------------------------------------------------------------------------------------•------- --•---------------•----------------------------•-•--------------------------------------- t -------------------------------------------------------• -----------------------------------------------------------------------------------------------------------------•--------------•----------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County v ordinances, State laws, addru-f and regulations the San Joaquin Local Health District. {Signed) - -. -G -lw�r Contractor By:_--------------- "' -------------------------------------------------------------------(Title)----4.C#-r8Z_ _ i -------- (Plot plan, sho n�,of_lot,_location d' system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ ---------------- DATE-- = ------- REVIEWEDBY--------------------------------- ---------- ----------------------- ------------------- DATE_.__ BUILDING PERMIT ISSUED DATE -- ---- ------------------------------------- --------------------------- Alterations and/or recommendations---- -- -- -------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------ --------------------------------- f ------------- ------------------------------,--------------------------------- ----- FINAL INSPECTION BY---------------- Date-------- � ----- -- ------------------------------------ ----------------- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT h 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 i N