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APPLICATION FOR SANITATION PERMIT Permit No. .. a .....---- (Complete in Duplicate] Date Issued .l6_`��' y Application 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. � ) Q r—, [ JOS ADDRESS AND LOCATION^ u----��--------"-... ---T, ----------STk� -----------� �. Owner's Name--------- ----•-•-------------�`-"—P--- ► ------�---_€-- Cr ----------------------------------------------------------- Phone-----&6-9-1-5----- Address--------------------------- - ------------------ -- -- --- - - c I. 0 �• -- -•------- Phone----------------------------------- Contractor's Name----------------------------------------- - ----------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ._ Number of living units. _--.--__ Number of bedrooms _-%3_ Number of baths ---L- Lot size --------- � _--�-Q-0-------�-_--.---_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table;--7- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E] Previous Application Made: Yes ❑ No V New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Xf' c Ta f' Mance from nearest well_________________Distance from foundation-------------------Material-----_-___-------.--_______--------..-_.-.-----. 5 No. of compartments--------- -,,/------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- I 0;s�l -,-------------------- Di�gl Field: Distance from nearest well__ Distance from foundation--_--!Q----.___-Distance to nearest lot line------> Number of lines------------- --------------- Length of each line-----------3-©----------.Width of trench------------------------------------ Type - ------------------- -------:---- f r 1► s Type or filter material_ _ x_ _ epth of filter material---____,_f8___.__.-Total length----..._------�-._�+_?_�_-__ Se pa e Pit: Distance to nearest well---------- --------Distancefromfoundation Ydation----- Distance to nearest lot line--- Number of pits--------i------------Lining material-- p ` �- ize: Dept-----.-- -_�--_- -- -----_ . -_- ` Cesspool. Distance from nearest well-----------------Distance from foundation--------------------Lining materiel------__-..-------------___--------- I ❑ Sizo: Diameter--------------------------------------Depth-..-_----------_ —Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- I' ❑ Distance to nearest lot line------------------------------------------------------------•--------- --------------------- ------------------------------------------ ----- Remodeling and/or repairing (describe)-----------------------j ---------------------------------•------------------- --------------- --------------------------- -------------------------.. -----------------------------------------------------------------------------------------------------------------•---•--------------------------------------------------------------------------------------------------- --------------------- -----------------------------------------------------------------------------------------------------._...--------------------------------------------------------- --------------------------- -. ' ------------------------------------------------- -------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------------------------------------------- ------ -------(Owner and/or Contractor) By: Of -� :�.,'�' '� - ---Title)------------------- (Plot plan, 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-----------•- - -- -- -- ----�--�------ , REVIEWED BY = -------------------------- -----• -------------------------------- DATE BUILDINGPERMIT ISSUED-----------------------------------------------------------••---------------------------------------- DATE------------------------------------------------------------- ' j Alteration and/or recommendations:---------------------------------- --.-. . _ ------------------------------------- ` S1 6------- ----- -- ---- �"`-�-- -- ---- ---------------------- -..--._- � ' --------------------------------------------------- ----------------------------------------------.---- - - _- - 1 1 ------------------------------ ------------------ _ • FINAL INSPECTION BY------ ------- ----- ------------ --- ---------- Date--------- ------------------ f " SAN JOAQ UIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oats Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES----9---2M-i0=52 Revised W-2100