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APPLICATION FOR SANITATION PERMIT• Permit No. .-�. (Complete in Duplicate) � ��/ Date Issued ------ -- Applica+ion 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: , 3— f ,/J f JOB ADDRESS A LOCA TI N..YX _ - -- -- - - c--- Ownet's Name---- -------- ame t------- ----- Phone ¢ Andress ' r ...__._-------- G s . Contractor's Name _ . .... ' ------------------- Phone--47A/- Installation hone_47A/- �C� i Installation will serve: Reside N Apartment House ❑ Commercial ❑ Trailer. Court ❑ Motel ❑ Other ❑ Number of living units: ----- Number of bedrooms _1_ Number of baths -Lot size--.__ +_7 -------4_ f Water Supply: Public system D. Communiiyrsystem ❑ Privateer l Depth to Water Table Character of.soil to a depth'of 3 feet: Sand-L] Gravel,❑"Sandy Lo m El--Clay,Loam.❑—'Clay ❑. Adobe❑ Hardpan + f Previous Application Made:;Yes f]'Y No ❑ ' New Const"�uetion:: .Y�s E] No ❑ I TYPE OF INSTALLATION AND. SPECIFICATIONS: ` .(Nonseptic tankor cesspool-permitted if public sewer is available within 200 feet.) Septic Tank: ". .Distance from nearesr well------------- °--Distance from foundation---------_------ ❑ No. of compartments Size --Liquid .Material clept/-------------------i1'---Capacity--------- --------- -- PiDisposal eld: Distance from nearest well.... D_Distance from foundation.- .�-f�._-.-.Distance to nearest lot line-10. Number of lines-------------�___---.._--.-> ----Len th of each line---` ,�? - �` " r g ------- --------Width of trench-- ------ - Type of filter material_._,_ ,---Depthof filter rriaterial::r__L'�-----.--_Total length_-'-;.--- -_O--__.--- r Distance to nearest well--- - - "Q__ --_Distance from fo na'ation_---_1 -.Dist ance,`o'nearest lot line-----ld------- See of e,Pi Number of its___--.-_.-! '' " A Lining material--- _Size: Diameter--.--_-: nape th------ -- Cesspook" Distance from nearest well_---------------Distance frcm�foun-lafion'.__.----L----___..Lining material------.----_- .-----:--------.______ ❑' r Size: Diameter---r------------- ------------------Depth----- ----------------------------------------------Liquid Capacity------------ ---gals. Privy.:,. Distance from nearest well- --------------- ---- _ .'Distance from nearest building-----------------------____--_-_------_ . . [�' Distance-to nearest lot line_- - - .. --------------------------- Remodeling and/or. repairing (describe)------------------ -------• 4 •--------------------------•-•------------••-- ------ _------------------------------------------------ -------------- ----------------------------------------------------------------------------------------------------------------------------------------... I 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 Joa in Local Health District. a 4r (Signed)---- or Contractor]------ --- --- ----------------------------------- -------------------= r B '-------- I y. - -•-- ------------- --- ----=------=--------------•(Title)------------------------------=------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y= FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------- -- -------------------------------------------- DATE---------------- --------------------------------------- REVIEWED BY -------------- ......... -•----------------- DATE--- - BUILDING PERMIT ISSUED----------------------------------------- ---------------------------------------------N'y---------- DATE------------------ t Alterations and/or recommendations---------------------------------------- --- ----- - -�r- --�'-------- !!` ----------- r � --------------------------------------------------- _ e 5 _ L ------•--- --- -- r -------------- 1r r = ----------------- - -_ � , �f ! ,r W 1 _1e1__ FINAL "INSPECTION BY:_: Date--.-- ---- ---- 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 i E5=9-2M Revised W-2100