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n APPLICATION FOR SANITATION PERMIT Permit t o. ......... � V (Complete in Duplicate) ,L 7 Date Issued Applica-%n is hereby madelto 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. H10 -k--------------------------------------------------------------- JOB ADDRESS AND LOCATION...... r Owner's Name------ -- -------•- F ----------•----•-•--------------------- -------------- ----------------------- Phone-------------------------------- Address........... a ---•----•-•------- ----------------------------- -------------------.....------- --.-- ----------------- •----------- --------- .��.�.�__�'..�.----------------------- Contractor's Name '""' ` -------- ------ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _--- Number of bedrooms _ _._ Number of baths ___l-- Lot size _ e�' s ! 2. ......... Water Supply: Public system Community system ❑ - Private ❑ Depth to Water Table 1 'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy-Loam ❑ Clay Loam ❑ Clay ❑ Adobe B- TAardpan ❑ Previous Application Mader Yes ❑ No Rr' New Construction: Yes ❑ No 24r. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 ext• Tank: Distance from nearest well------------------Distance from foundation--------------------Material____.-__--------._.___._____________._____.___-. No. of compartments-------------------- - ---Size---------------•------------•---Liquid depth--------- ----------------Capacity--- ----------------- i � 22 Di sa Field: Distance from nearest well_.oQ..____Distance from foundation_=s� ---------D'sstance to nearest 14,tne__ _ ____. Number"of lines------- ------------ � }/��Length of each line-------J--,& -�---------Width of trench----_-/__f_.___--------------------- Type of filter material_, Depth of filter mate rial_.-/f��r-`_-.Total length_____J70-*-___________________f. .I Seep Pit: Distance to nearest well_'-Distance from oun ation__�.�.______-.Distant a to nearest lot line�.J_7____. Number: of pits.._.__-------------Lining material-_d4 Size: Diameter__9�.__._ ...... 9� -------Depth -��- °� ---------------- N Cesspool: Distance fromnearest well-----------------Distance from foundation-----.---------.___.Lining material--------------------____.___________ _ Q ❑ Size: Diameter--------------------------- ----------Depth----- ------------------------------------ ------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well---________--------------- ------_------------ __Distance from nearest building-------------_--_________:_______._______- ❑ .. Distance to nearest lot line.------.. --------- --------•--------- -----------------------------•------------------------------•------------------------------------- Remodeling and/or repairing (describe)-----------------,-1 -�- •------------- ---------••---------• --•------------•---------•-----•--------••---------- ---------------=------•--------------•----------••------------•--•- •-----------------------------•------...----------------------------- ________ ._ _ -----------------•- --------------...--------•---------------------•-----------------------------------•--------------••------------- ------------------------------------------------------------- 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) -'= -------- «— •(QV#4%- --A/- Contractor) By: •----------- --- - ..... -+-.�- - - - - ----------------------------•-----------------------•(Title)----�W ---------------------- (Plot plan, showing size ot, location of system in relation to wells, buildings, etc., can be placed on revers ide). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ---------- = ` DATE .. REVIEWEDBY-------•------------------------- --- -------------- _ DATE----- BUILDING PERMIT ISSUED------------------- -- ------- - DATE-------- ------ -----------•- Alterations and/or recommendations: r -•-----------------------------•---- ----•-•--•-------- --• ---- -& ------------------------------- ---- -- - -- --------- -..- T-------------1-------------- - --------------------------- -- ------------------------------"-- -------------------- ------ -- INSPECTION BY: --------- ----------------- FINALDate....- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California EF9 345446 ATWOQO + x Jj