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-5 2 APPLICATION FOR SANITATION PERMIT � (R (Complete in Duplicate) Date Issued µ � � e0 r ��A�plic`ation 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. JOB ADDRESS AND LOCATI 9 -� _ � �'l�.,J-=--- ----- - -------------- Phone_ ---�T-�-'r�--`��------- Owner's Name-----------------•--------- -•• --- -------- ----- --t--- Address_... ='- ----------------------------------------------------------- ----------------------- -- -- Phone------� �c- per~'----•- Contractor's Name----------------------------------- Commercial Trailer Court ❑ Motel ❑ Other ❑ Installation will serve: Residence Apartment House ❑ ❑ � , �4 /�� -_ Number of baths --/-__ Lot size ------------------------- Number of living units: ___1__ Number of bedrooms ---Y ' Water Supply: Public system ❑ Community system ❑ Private, ___.__ Depth to Water Table _ _ ft. ndy Loam El Clay Loam C3 Clay E] Adobe[ Hardpan E]Character of soil to a depth of 3 feet: Sand E] Gravel (DSa Previous Application Made: ,Yes ❑ Nom New Construction: Yes,Eq .No ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: _ ailable within 200 feet.) (No septic tank or cesspool permitted if public sewer is av, lQ--------=.Material--N-- ----------------------•-- Septic Tank: Distance from nearest welL_1Q_'__Distance from foundation__--- - Ca acit t��---- & No. of compartments Size-- -- Liquid depth------`� P Y -�--- , � - „� Disposal Field: Distance:,from nearest weII�Q------Distance from foundation____----=------Distance to t nearest lot line Number".of lines------,�--------- --- ��'' -Length of each line--- /,P-G '�`- Width of trench------ _y'-=-------- Type of filter material__.__/__�__- --Depth of filter material-__--_� ---------Total kength______ E___Q__4_______________________ Distance to nearest lot line ____________ w Seepage Pit: Distance to nearest well______________________Distance from foundation_____.____._---•-- ___-____-___ Depth____----------------------------- ❑ Number of pits---------------------Lining material-----------------------Size: Diameter----, Cesspool: Distance from nearest well-----------------Distance from foundation--__-------------Li ing material, (A Size: Diameter------- --------- -------- ---•----- Depth _ . quid Capacity---------------.____.__.___gals. ❑ - Privy: Distance from nearest well________________________________________ '__Distance from nearest building------------- ---------------------------- --------------------- _ --- ---- ❑ _ Distance to nearest I�line------�-�--- - ------------------ ------- �----�---""-- Remodeling and/or repairing (clescr b ] �-� ---------------- --------------------- ----------------- -------------------•--------------:----------------=-----------------------------------.------------------------------- I hereby certify that I,have prepared this application and +hat the work will .be done in accordance with San Joaquin County ordinances,�state laws, and rules 4—regulation af't a San Joaquin Local Health District. -z c---� _ " -- -- �•- - rmernd/or Co tractor] r ----------------------- = = •• Signed -c --------`�------ -- ' -------------------------------------------------- y ----�---------(Title}_ - B �---------------- �- -• --- ----- ----------- 1 (Plot plan, showing siz of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -------- -- -----------------=----- -- DATE---------- ----- �_ _ _ �� ------ -- REVIEWED BY------------------------------------------------ -- ----------- ------- DATE------ --- ---------------------------- -- s BUILDING PERMIT ISSUED-------------------------------- ---------- ------------------ ---------------- -- ---------------------------------------------- Alterations and/or recommen ations----------- ------ --------------------_- -__------- ----- ----------- d �� ---� FINALINSPECTION BY-------------- ---------------------------- Date------ -------- -------------------- --------------- ----------------- ---------- r 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' ES-9---2M 8-51 Revised W-2100