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APPLICATION FOR SANITATION PERMIT Permit No-,� j-_ . (Complete in Duplicate) Date lssued/l/-::-f________.-- 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 Ordinanc No. S49. �J c JOB ADDRESS AND LOCATIO. . a •--•- - . . --- f ------/ --------------------------------------- Owner's Name------�'-. -1-- -.. - -•• ----------------------------------- - ---------=-- --------- .- Phone------------------------------------ Address....---- l - -- �' �--------- ------------ -------------`'-'--"--------------------------------------------------------,-----------------.p-- -------_---�r---------f- ----- Contractors Name___i____ _____ ------------•--- Phonel Installation will serve: Residence Apartment House L] Commercial F] Trailer Court ❑ Motel [I Other ❑ ,Number of living units: __I.___ Number of bedrooms __2�_ Number of baths _1____ Lot size ____ _ _-x___r ' Water Supply: Public system A-1:1-0mmunity system ❑ Private ❑ Depth to Water Table P. ft. Character of soil to a depth of 3 feet:. Sand ❑ Gravel ❑ Sandy.Loam ❑ Clay Loam ❑ Clay @1-'Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ 'No l!Ef— New Construction Yes —No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se tic Tank: Distance from nearesr well47�� __Distance from foundation___ __ _ o___ _ aa _____.Material____ ____________________ ___ .___________. pNo, of compartments---------„�--_---------Size-Ok�--�_-��--•_--Liquid depth----�-�- t--_Capacity------�'s'�----- Disposal Field: Distance from nearest well_-C_Distance from foundation------�_O.......Distance to nearest lot line---- V � Number of lines-_---1--------/------- Length of each line-------, -©--- -------- Width of french------:QVC-/-i---------------- Type of filter material___f'__r-___ �=Depth of filter material-____>E, `_.__.____Total length_____,a_�______________________� Seepage Pit: Distance to nearest well_- --__Distancepfrom�f undation____. 1 __t..Distance fo nearest lot line_____________..___ [ .. Number of pits-........_/----------Lining material...RA4A ----Size: Diameter__.��______._.___.Depth_-_,_P �_____--_______-__ Cesspool: Distance from nearest wekl-----------------Distance from foundation--------------,--__.Lining material__.___________.__----_____r_________. [� Size: Diameter------- ---------- Depth------------------------------------------------ --Li uid Ca'aci - als. 3 q p ' - 9 Privy: Distance from nearest well--------------------------------------------------- from nearest building------------------------------------------ El ____________________________- _-_..._.❑ `Distance-to nearest lot line----------------------------------` I � Remodeling and/or repairing (describe):------------------------------- ---------------------------------=----------------------------=----------------------•----•---------------------------- ---------------------__----------------_____-_________-___________________._.___--.-.-____________._--_____-_-___________.__...._____�____•--.-.--____________.___ ---------------------------------------------------------- ~ ------------ -- .. ________________________-_--__.________- -________-_--_._.---------------------------------------..------------------------------- __ .. Y i , r. _--------------------------------------------------_________________________________________________________________________________________________________________________________________________________ I hereby certify +heat-I-have prepared thisr_applica+ion and that +he.work will be done in accordance with San Joaquin County 4 � ordinances, St laws,l nd rules..:a d regula+ions ref-tile 'San Joa,juinkocaVHea fh District. + ---------- --------------=----- - ----- Owner-and/or,Contractor * - �,, t LL ^�.. = Title) I (Plot plan, showing size'of lot, location of system in relation.to•wells, buildin s, etc., can be placed on reverse side. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- --- DATE-------- ------- --------------------------------- REVIEWED BY-------------------------------- ' ---- ------------------------------------•--- DATE L ------------- BUILDING PERMIT ISSUED-------•-------•-----------Z- _ DATE----------------------5------------------------------- Alterations and/or recommendations-------------------------------------------- ---- ------------------------------------ t----------------------------- - ..... ------ -------------- ----- ---------------------------------- ---------------------•--------------- J q FINAL INSPECTION I-BY:------------ -Z S.�_----------------------------------- Date---------------3 ..._ ---l- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 914 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M I ' Revised W-2100