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APPLICATION FOR SANITATION PERMIT Permit No. -�C?�. ___.._ (Complete in Duplicate) Date Issued -_-------------------- Applica4ion 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 Co`u'nty Ordina co No. 549. JOB ADDRESS AND LOCATION `' 1 ----------- Owner's Name J _- -.- ✓. - J------------------------------- -------------- -----------------.... Phone----------------------------------- st Address ---..... r. . / ---•- --------------------------------------------------------------------•------------------•-------------------------------------------------------- Contractor's Name ------------------------------------------------ ----------------------- Phone Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _J----- Number of bedrooms -------- Number of baths -j---- Lot size -Q�..xzaa---_------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.Xf, Hardpan ❑ Previous Application Made: Yes ❑ No X_ New Construction: Yes ❑ No4 TYPE OF INSTALLATION AND SPECIFICATIONS: p At: epfic tank or cesspool permitted if public sewer is available within 200 feet.) e , Distance from nearest well-----------------Distance from foundation--------------------Material_----_------.-------.-------_-__---.-----------. ❑ No. of compartments-- ------Size----- --------------------------Liquid depth--------------------------Capacity----------------------- r-x1 � , c, Disposal F�e�: ] Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--------_---__--- ❑ Number of lines----------------------------------Length of each line------------------------------Width of trench.--------------- .-------------. Type of filter material_---- --------------Depth of filter material----------------------- length---.---..-_-----__.-------_----_----__.-. Seepage Pit: Distance to nearest well_�/6/+�.`4�,_Distance from foundation---_f-_0----------Distance to nearest lot line{--6_-------- Number of pits.--.--_I__-_-__----Lining material-- Size: Diameter-_..-B_G..-r------Depth-___ ------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------------------- -----. N 1] Size: Diameter------------------------- ------------Depth---------------------• -----------------------------Liquid Capacity---------------------------gals. v Privy- Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line----------------------------------------------- ----......--------------------------------------------------------------------------- , - ----- �._-. Remodeling and/or repairing (describe):-- -------- -'�-1- -•--- ---------------•-------------•-----•--•--------------------•--•----------------- •------------------------------------------------•-------------------------------•---------------------------------------•-------------------------------•--------------------------------------------------- ----------------------------- ------�- -----•--------•-----•---------------------------•-------------------------------•-----•---------------------•-------•---•----------------•--------------------------- I hereby certify th t I have pared this application and that the work will be done in accordance with San Joaquin County ordinances, State ,land r s ¢r d regulations of the San Joaquin Local Health District. (Signed)------- �_. -(,_Iae, ------------------------ -------------- -----------------------------------------------------(Owner and/or Contractor) By: ........... --------------------------------------------------------------•---------------------------------------(Title).---•----------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- DATE REVIEWED BY - ---------------------------------------------- DATE BUILDINGPERMIT ISSUED-------------------------- - ----- ----------------------------------------------------------------- DATE--- Alterationsand/or recommendations--------------- ---- -- -- -------------------------------------• ------------------------------ - --------------` --`-------•----------- --------------------------------------------- ----- --- ' ----------------I---- -------------------------------------------------- -----------------------------------------------------------------------------------•--•-------------------------------a---------------------------- -----•-•-•-------------------------• ------------------•------------------------- ----- ------------------------------------------------ -------------------------------------------------------- -------•-------•-.---- -------------------------------------------I-----------------•------------ ----------------------------•----•--------------------------------------------------- ---- ----------------------------------------------- yg_ 5FINAL 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 ES-9-2M ; Revised W-2100