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APPLICATION FOR SANITATION PERMIT Permit No. !} . -3-1-'-,-- (Complete in Duplicate) �� )rnade Date Issued� 77. ._. ._..._..3 /70—�Z:ppli tion is hereby to the.San Joaquin Local Health District for a permit to construct and install the work herein described. this applicptio'made incompliance�with County Ordinance No. 549:• JOB ADDRESS AND LOCATION._ G '.._..... ----------------------- ....6 ve...��. -._._.... - Phone._ _._ -------------------------- Owner's Name.......— .... ij• ........ L Address ........ f� ----•----------- ---- s ~Y^'�`... r Contractor's Name----------------- --------- .Q -------------......_ -------------------- . ...--•----.. Phone................................... Installation will serve: Residence Apartment Hose.❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: .. .___ Number of bedrooms _..Number of baths ./.... Lot size , Water Supply: Public system ❑ Community system ❑ Private� Depth to Water Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe ) Hardpan ❑ .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.) e Septic Tank: Distance from nearest we l_.�` 7-d.�Distance from foundation_10.... .....Mate No. of compartments_._.., ____�.....Size... Liquid depth.... ._. '-------...Capacity-, ... Disposal Field: DistancNumbeeofol n nearest Weil. Distance from foundation.....�.__.._.Distance to nearest lot Iini-2810I v ` � � � Length of each line.._.f��s1- 8- Seepage Width of trench._. . ,. ------_ _- Typo of filter material--..i- Y?' Depth of inter material..... .........Total length.._. _X7......._.._.__..__ Pit: Distance to nearest well-...._...............Distance from foundation........_____......Distance to nearest lot line-. .Number o'1p;ts Lining mafiericl - Size: Diameter..._...-- -------- .Depth---------------------------- Cesspool: Distance fi:om nearest well---..........----Distance from foundation__ _. ..........Lining material-.......... 77 Size: Diameter---...................................Depth.........-------------..- _..------ ------------,Liquid Capacity-------......-•----- -.._ .. _7 _ _... ._ _- .-T----- ,...�_�.•...-.rte • -- ; -„.^--<----�r — - ,-rivy: Distance from nearest.-_..well.............._..-T-......___._.__._......._.__.Distance from nearest building ....._._..t_.....-................... _. ❑ Distance to nearest lot line..._-_ Remo eiing and/or re airi escri ............--------------•----------------------- ............ ........---------------•-•--•-•---------------- -...................................................----•----- .—....._............ 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 Joaquin Local Health District. (Signed)... ...... rr �.� _..... .......- (Owner and/or Contractor) ay.----- ---------•----------....-----'---------- ----•------- -.-..(Title)------ ------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ji FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY................. ------ - ...... ...... ----- DATE---- -- ------------- -- REVIEWED BY..------------------------ '-•-.... /��!/ --------- - � DATE......... --�---- ---�........ -- ----- BUILDING PERMIT ISSUED. ...................................-•..... DATE..................................... Alterations and/or recommendations---- --- - .......................f......------•--........;......--------- ..----•---- - �1 .........-•---••---....---•--•--- ..._--------------------------- ............... .......................-•-•-------•---•--............................................-•......--••------•-------•----- - ._._............-..-•--• ----•----------------- •----------••---•-.---.......---._....---..._..._.......---•--...•---.... .................-........... ..........------- ..................... ............_...................... I ..... -•---.---..-----.-.-•--------.--.__--.-•-------------------.----.----•---------- ------------------- --------------------------------- ............-----. ....--•---------------. '- - C'r - •----•----•-----. ..._.... - --•--........... FINAL INSPECTION BY:......-L.... -.-...... -... Date- SAN ate..SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C” Straet Stockton, California CI Lodi, California Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100 I