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q APPLICATION FOR SANITATION PERMIT Permit No. .... J---- (Complete in Duplicate) Date Issued ___ A hca}ion is hereby made to the San Joaquin Local Health District for a permit t6 cons rust end install the work herein describe . pp - This application_is-made in compliance with County Ordinance No. 549. , JOB --------------- ADDRESS A "CAT111ONN1...______:... U---� _ , 7��a 94 ---------- Phone----------------------••----------- "`Owner s•Name-------- --- • =f ------- " 62 -7- 0�a0— 6 ii�t Address____. i_o ` --- ---- - r� -- Contractor's Name____::�_____ _____________ -------- - - - - Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [I Installation of living units: ___I___ Number of bedrooms __�-.-" Number o-baths ._�__._ Lot size _�_.��.-_- F Supply: Publics stem ❑ Community system ❑ Private Number to Water Table ________ ft. WaterY Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ R 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,=5 D stance fr cn`fo r�dation____ ______.__-_-_.Materi�l_" ----Capacity---_X100 .,c�ri No. of compartments----------9.__a__. �� !�-- ----•Liquid e th__ ------ ' ---Size------------ ---- -- - q `� �,p'.�,,� r - ---- istance from foundation_ _:-h'"`" Distance to nearest loft i e Disposa Field: Distance from nearest welly.-_-.__-_ t-- -- ---- Len Length of each line__-_----_- Width of trench---_�'[_-_ -------- Number of lines----•------�-- �---------- - - g p�---. ` f-------- Type of filter maferia4 !�Depth of filter material___-._}�- Total length t �� Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------_--------Distance to nearest lot line_______-___.____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation----------_---------Lining material-----------------------------"- als. ❑ Size: Diameter---------------------- ---- -Depth----------------------------- ----------------------Liquid Capacity-----------------------•---g Privy: Distance from nearest well---------------------------------------- =-"---"Distance from nearest building--------------------------------- - 4 ❑ Distance to nearest lot line-------------------------------- ------- ----- - ---------------------------- Remodelingandor re yaiPing descri�e . ---------------- P 4---- 6-------------------- n -•----- --•--------� ----___ ...--------- ------------------------------- -----•-•-----••---------"--------------- -------------------•-----------------•----------------•-------------•-----------------------------------------------------------------------•--•-----•----------------- --------------------------------------•---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ?,7N ordinances, State laws, and rules and regulations of the San Joaquin local Health District. (signed)-------L_"______ -a----- - ------•------------------------ -----(Owner and/or Contractor) t -(Title)---------------------------------------------- --------------- r = By----------------- --------- ------- ------ ------------------------------------------ f (Plot plan, showing size of lot, location of system in-relation to-weIls,;6uildings,_etc-, can'-be placed.on reverse side). ry FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BYE----- ------------ --------- --------------- -- ----------------- DATE_- REVIEWED BY--------------------- . DATE__ 5; ---------------------------------------------------- ----- --------------------------------------- DATE BUILDING PERMIT ISSUED_____________"-"- ----------------- If Alterations and/or recommendations:--- ------- -- ------ - -;-----•----------------------------------•-- -------------------- --------- - --;;�'`�s�----.----�is � ' ----------------------------------------------.----------------- ' ------------ ---- ----------------------- -- ---------------------------------��--------------------------------------- ----------- ---- -------------------------------------------t -------------------------------------------------------------- --------------------------------------------------- -------- --------------------------------------- -------- FINAL - ----- --- FINAL INSPECTION BY----------------------•-------- -------------- - Date--- ---------------------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 sycamore Street 814 North "C" Street 130 South American Street Trac California + Stockton, California Lodi, California Manteca, California Y. 145446 Prw000 —11