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1 APPLICATION FOR SANITATION PERMIT Permit No. ..4.� .. .... 9 3 (Complete in Duplicate) � 3 ` Date Issued _____V_ -- A lication 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 Ord:inance No. 544. " JOBADDRESS AND LOCA JON------- ..r✓/_ ----- -------- --•-------------------------------------------------------------------- ' !�__7-------- Owner's Name-------a =- Address ` `� .----- - j -- {P - - -- - --- Contractor's Name. , -• '-----------=---------------- ----=------------•----------------------- Phone --a ------. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .__f__ Number of bedrooms _A-- Number of baths _L__ Lot size -_..._____"-------------------------- Water Supply: Public system 2--1cl-ommunify system" ❑ Private ❑ Depth to Water Table .TQ_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe E-10ardpan Previous Application Made: Yes ❑ No New Construction: Yes ❑ No s TYPE.OF INSTALLATION AND SPECIFICATIONS: a��_ (No septic tank or cesspool permitted if public sewer is available wit in 200 feet.) Septic Tank: Distancefrom,nearest well___._"_____--`Distance from foundation____________________Material-___--.._-__.__.___-__-_.________._________-__. .. : .. ❑ No. of compartments----------- -----------. 'Size---------------------------------Liquid def?sh--------------------------Capacity-----------•----------- Disposal Field: Distance from nearest well f� `�� Distance from foundation_____ __..._.Distance to nearest lot line__- Q"____. [jam Number of line,__!? .•�"" th of each line__ _____ Width of trench. Type of filter material_/fi>1__..____- Depth of filter matenal____.__ .__.____Total length----------1Q___------------------_---- rest _____ ________..__"_ Seepage Pit: Distance to nearest well --Distance fr f`ou�d' ion___�e-------Distan� to nearest lot line4.•_.3f�_____- Number of pits-------.------------Lining material_L_�_C � .Size: Diameter_____.3.�______...Depth----c?��_________________ Cesspool: Distance from nearest well-----------___-Distance from foundation-__.________.------Lining material__.__._.____-__.---_________________. Size: Diameter------ -------------- -------------- _1 Depth------------------------------------------------:----Liquid Capacity....------------------------gals. Privy: Distance from nearest well--------------- ---------------Distance from nearer# building ----- E] Distance to nearest lot line______________ ---- ------------------------------------------------" Remodeling and/or repairing {describe: '------ ------------------------------------------------ --------•----------------------------- --------------------•--------•--•----•------------------------•---"----------- ----------------------- r t ________ _ _ ______________________________________________________"_..-_______-___..._...______~_-._-___________.______-____-______________-____________..____-__-._.________.__.__i__.__...___ I hereby certify that I have prepared this application and that the work will be-done in accordance with San Joaquin County ordinances, State s, and rules and regulations of the San Joaquin Local Health District. (Signed)------- -•- --- - - ------ --- ---------- -----------------:---------------- ----------------------------------- -------------- * and/or Contractor By:------------- ------ ---- ------- ------------------------ ---------------------------------------------(Title)--- -------------- ------------------------- �. (Plot plan, showing size of Eot, location of system in relation to wells, buildings, etc., can be placed on reverse side]. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------------- --- ------------- ------------------------ DATE ----------- -`-------------- REVIEWEDBY------------=;---------------------------------------------- -- -------- DATE S ,`------------- BUILDING PERMIT ISSUED---------------------------------- - ----------------------- RATE.. ;; ` Alterationsand/or recommendations--------------- -------- _ - ---------------------------------•-----------•--------------------------------------•-•--------•----------------------------- --------------------------------------------------------------------•----------------------•------------ -•-•---------•-•----._:.-----------------------------------.".. -_---•------------------ --------••-------------------------------------------------•••-----•----- ------------------------------------- ------------------------- --------------- FINAL INSPECTION BY:..------ 4�--------------- 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 ES-9=2M I0-52 Revised W-2100 a ^