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APPLICATION FOR SANITATION PERMIT Permit No .3..6_... (Complete in Duplicate) Date Issued --------- Applica+ion is hereby made to the San.Joaquin Local Health District for ! rmit to construct and install the work herein describe This application is made in compliance with County Ordinance No. 549. y S �faiuY yr 04 JOB ADDRESS AND LOCATION---- 111- - ------AX-- -3-# A - ��° =-- /' L 1 f Owners Name-" ame- ----------• -------------- �l J� h�1/1D ----- ==-== ---- - ,- -- -Phone. --•-------- -- Address - --------------------- Contractor ---------- Contractor's Name---------------------------------------- ' l �ill� ----------------------------------- F Installation will serve: jResidence Apartment House ❑ Commercial ❑ Trailer•Caurt ❑ 'Motel ❑ Other ❑ : Number of living units: --------- Number of bedrooms __----- Number of baths ---I---- Lot size ------ QCa_.___ __:a_S_ O______________________ Water Supply: Public.-system [I'. Community system ❑ ."Private Depth to Wafer Table" _'ft. � t Character of soil to a depth of 3 feet: , Sand ❑ Gravel ❑ .Sandy Loam ❑ Clay.Loam E] Clay ❑ Adobe Hardpan ❑ t Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: L(No 'septic tank'or cesspool permittedif pdblics ewer is available within 200 feet.)` Septi Tank: Distance from nearest well-_`_i5, ti from i foundation_____fL__. ..__Material __________ ____________ ____ No. of com artments____a___ --------Size � ,3_-_Liquid de th------._)x ...........Capacity `1l---- Dis osal Field: Distance from nearest welL._..75:- .J Distance from foundation.------>' ---------Distance to nearest lot line----- "Number of lines.__•-- _-- -- --w._--____--=Length of each line---------- --�`i__--.Width offrench----------- -�,1��-------------- Type OT filter mate`ial___-__�_ __.1 (___Depth of filter material__.---_--If._-_-._-Total length--.-__-_-7.7------------------------- Seepage Pit: : Distance to nearoe st.well..............._!Distance from foundation___----_-- _.--.__.pistance to nearest lot line------_-----_-_-- Number of pits_ ---- ------Lining material-----------------------Size: Diameter------------------------Depth----------------------:---------- Cesspool Distance from nearest well----.- ___.--_fDistance from foundation Lmm material--.- --_-__--_'-_------- .,.... Size:Diameter:___- . --. De the ; . € w 1- `Li uid cCa acct els. 0� .�.� -----------" - P ----- ----- - . q P Y 9 -._ Privy:;_ Distance from nearest well-_'_-____-------------------------------------Qistance ;from nearest building _:_.__._______________._._. ❑ . .. - - Distance to nearest,lot line.. = 4". "" ., b -------- -g-------------- ----- ------------------- Remodeling and/or p g (describe):------ -- - - nd or re ainn describe :_ ----------------------- } - ----- fi ; . - , _-. �� ----------------------------- ----------------- -... -- -- t;--- ' -` hereby certify that I have prepareg this application-------------- ----------- •_.._.---------------------: ---------------------------------�--•----- -•" ------------- ordinances, State laws, and rules and r Mations li ation and 'that the work will be done in' accordance with San Joaquin County the San Joaquin Local Health District. . 1 (Signed)-------- ----- -------•----•----------------------- -------------------------------- --------------------=------------------- -----A------ ------(Ownerand/or Contractor) Plot la , showisize of,lot, location of s �------------ `-----------------------(Title)--------------------------------------------------------------- ( p g yste in relation fo wells, buildings, a+c., can be placed on reverse side). r a : s FOR DEPARTMENT USE ONLY } 5_ 1 APPLICATION ACCEPTED BY-----=---- ----------------------------- DATEI�- { t -------------------------------- DATE--------- _l.__ .__� ,1 K REVIEWED BY--------------------------------------------------------------------------- --- BUILDINGPERMIT ISSUED----------------------------------------------=------------------------ ......---------------- •DATE----------------------------- ------------- =•-•--- Alterations and/or recommendations: - -`------------------------•---=---------------------- ----------------------------------•-------•-•----••----------------•--- t 1 F F . ----------------------------------------- e�------------------------------------------- FINAL—INSPECTION BY:�.__ _ _ -Date:` /r - = - -----=--------- -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stra4t 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised,W-2 100