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APPLICATION FOR SANITATION PERMIT Permit No. ! - t (Complete in Duplicate) Date Issued 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. "f-4l JOB ADDRESS AND LOCATION------_-_1--�----/-......�-4------�--Z--------•----------- ------------- -- ------------------- - ------------------------------------------- Owner's Name--- �_ta_ ! W-1-Jkep---- ©h---------------------------------------------------------------------------------------- Phone---- ----------- Address----6-0-3.. ltc�r t2 lae- -----��---�---ff--------------------------------------------------------------------------------------------------------------------------------------------------- Contractor's Name---- .Q_L. - -W-1_�-k_ eU_s a),------------------------- ------------------------------ Phone---C,� � 2 0 Installation will serve: Residence ;A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_!----- Number of bedrooms ____t Number of baths .-I----- Lot size --------- ------------------- Water ________________ Water Supply: Public system PQ Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobea Hardpan ❑ Previous Application Made: Yes ❑ No 4 New Construction: Yes V 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__kl_0!_'eDistan from foundation---1_Q_r.______-Material._.--- ��W '�� No, of compartments__.___ ___.____Size_____ __ Liquid de +h.______4�_.'..._.__.__ Capacity---- !?___ -------- --- t Dispolial Field: Distance from nearest wefL)24��._Distance from foundation_L41___7___.Distance to nearest lot line__._..........N, Number of lines-------------2—----------------Length of each line---- --- Width of trench----- .__ ______________- Type of filter material__ss�__��_Depth of filter material-----f-- '-_---__---Total length___-_.�i ?_________________________ 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------------------------------------- ❑ Size: Diameter-------------------------------------Depth------ ---------------------------------------------Liquid Capacity---.------------------------gals. Privy: Distance from nearest well-----------------------------------------------.-Distance from nearest building--------_.__.___________________..___.._. ❑ Distance to nearest lot line-- --- ---------------------- ------ ---------------------------------- ---------------------------------------------------- Remodelingand/or repairing (describe)--------- ---------------------------------------------------------------------------------------------------------------------•--------- -------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Late laws, and rules andel regulations of a San Joaquin Local Health District. (Signed)-- -- - --- - ---------' ------- ---------------------------------------------------------jOwner and/or Contractor) By:---- = { ' ---� . - --------------------------------(Title)-------------------------------------------- ---------------- (Plot plan, s mg size of I , location -,Sys em z:elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY 1 -� Y ------------------------- DATE-------- . REVIEWED BY------------------------------------- ------- ------- ---- DATE- ------ ----------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations------------- ---------- ---------- - -------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------------------------------ -----------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------•-------- FINAL INSPECTION BY:..--.L ° 1 !/LJt ------------------ Date. `� C ------------------------•------- --------- ---- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-7---2M : Revised W-2100