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APPLICATION FOR SANITATION PERMIT Permit No. .. .- 1 0 (Complete in Duplicate) J Date issued L pplication is hereby made to the San Joaquin Local Health istrict for a permit to construct and install the work herein described. This application is made in compliant i Count Ordina Na. 549.: JOB ADDRESS AND LOC " 4 ------------------------------ Owner's Name- - - - ----------�-------------- -- ------------ ---- ----------- - -------- -------------- - --�------ Phonee--------�------------- ----- Address -_ c„1 � j� -'- --- { G` ''p-- r"� Contractor's Name---------------------- .._... ------------------------------------� Phone----5-.;XO�'----- Installa+ion will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I--- Number of bedrooms _',Number of baths _f---_ Lot size ._-_ ----------------------------------- AT Water Supply: Public system ❑ Community system ❑ Privat Depth to Water TablejJ_ ft.CPA- Character of soil to a depth of 3 feef: Sand ❑ Gravel ❑- Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob4 . e Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No )] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if puj3plic sewer is available within 200 feet.) "s Septic Tank: Distance from nearest well_ _._-----Distance from fouidation_--_�-----------Material-�'------------------------ - ------ No. of compartments-----------�------_.Size�Z._-_rc-�----____Liquid depth....- 1-__---_--Capacity----------------------- Disposal -- -____--Disposal Field: Distance from nearest well --20--__-Distance from founclation-___ __--__.Distance to nearest lot line_---- Number of iines-----------Z___�_-----_ -___Lang#h of each line___s Q_'-_--------_.Width of trench.: !----------------- Type os filter material-__-� to --Depth of filter material----.---AOT_!---_Total length._& -''--------------------- ---- Seepage Pit: Distance to nearest well_/t ____Distance froA foundation...... tante to nearesf lot Number of pits------I---_-r_-_)Lining material- ____.- ____' ___Size: Diameter___----��----.Depth---jpq -------- Cesspool- ----UCesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material Size: Diameter------- ------------ --------------Depth------------'----------------------------------------Liquid Capacity-- - ---gal'. Privy: Distance from nearest well----------- -----------------------------.--_.____Distance from nearest building_, ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodelin and/or repairing.(describe -------6_w::444Q ----- --fix �------ " �---------- ------------------- --------- ---------------- - --- - ---- r Z- - 3 _--------•---•-•-----_____---------------------------------------------------------------------------------------------------------------•____..........__---•----_-_-_------_-----_-___-------------------------------------- ---------------------------plaws -------------------------------------------�p--------------------------------------------------------------------------------------------------•--------- ------ ------------- I hereby cea+ I have prepared Qk application and that the work will be done in accordance with San Joaquin Count ordinances, Sfatand rules and regulafii ns of the San Joaquin Local Health District. Si ned -��--- -----------1-_--_-_ --.--- r Contractor( 9 )_---------- ------------- ) By:------------------- -. ------------- ----------------------------------------------------------------------(Title)-----_�v_ _a --I.t � -------- (Plot plan, showing siz of lot, location o system in rela#ian to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED,B -- --------- -- DATE REVIEWED BY -------------+----- ------------------------------------------------------------ DATE ��.----------- BUILDING PERMIT ISSUED------ --- - -- ------------------------------------------------' DATE Qn Alteretions and/or recommendations: - ------=-----------------------------------------------------c:_ -•--------------------------•------------------- ----------------_...-----------------------------------._.-...--------------------------------------...-..-------------••---------------..-..---•---...--•--------------------------------- ----------------------•---•-- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------- FINAL INSPECTION BY------------------ ---`----------------- Date........ ------------------------ 1- e- ---- --- ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Stroef - Stockton, California Lodi, California Manteca,'California Tracy, California ES-4-2M l0-52 Revised W-2100