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\/ ,y A APPLICATION FOR SANITATION PERMIT Permilt I o. .45... .....¢ (Complete in Duplicate) Date Issued __ - Applica+ion is hereby made to.the San IJoaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance withCountyOrdinanc No. 549. JOB ADDRESS AN OCATION-------•�/----- 3-�-=- -- -------`----------------- , ------------------------------------ / ------------ Owner's Name-------- ----- • --- - ----- -- i : .. .--• - ---------------------------------------------- --------------------- Phone -I Address---------- ----1------`-3 = Contractor's Name ----------- ---•-- A""�----------------•--------------------•-------- •-� -------••------••- – `v - hf Pho n _ Installation will serve: j,Residence Apartment House �] Commercial ❑ Trailer Court ❑ Motel E❑ Other:❑ Number of living units: ---/__ Number of bedrooms _J___ Number of baths -__ __ Lot size -S"_ _10--Q_________________:___.__._ Water`Supply: -Publicjsystem-[ r"Communify system ❑ Private ❑ Depth to Water Table -Yo ft. , Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Constru ti : Y s No < TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 '.,. Septic Tank: Distance from nearesr well-_______________Distance from foundation.___-___:-____ p _. Dis❑osaI Fief Distance from nearest weil.._,...___:___:.Distance from {o Liquid depth___________._________,_Capacity________ ___________ r No. of'eom artmen_ts_..- ______.___Size_________________ ___ p undation__-=___--___.--_-.Distance to nearest lot line._- --- ❑ Number of lines----------------------------- -----Length of each line-----------------------1-----Width of trench----------------------------------- Ty'e of filter material---------- -------------Depth of filter mate 'al------ --__- 1-. Total' length-----------------------.-----------------._ Seepag it: Distance to nearest well--_--77! _ _.___Distanc fro fou dati ` Dista c to nearest lot line------___._ Number of pits._.. ._________Lining material_____C. r Size: Diameter`.�-�_- ----Depth-____.sal -- - - Cesspool: Distance f36rrs nearest well: -_._--._,:.Distance`from foundation------------_ Lining material__-- ❑_ ' Size: Diameter.--- -------- -----.Depth------ -------- --- ---------------- _---Liquid Capacity----------------------------gals. A, ir Privy: ; Distance from nearest well--------f--------------- ------- ----:_:__Distance from nearest building..-----------------------------_._------ Dis --. ❑ , ...� tance to nearest lot Ione-------------=-�---------------------------------�----•----•---•---------- ----- ---� --- ------------ Remodeling and/or repairing (describe)---------------------------F •--------------••-----------------•------•-------------t--------- •------- ---- --------------- ------------ 11 = ----------------- } j ---------- --- ----------- ----------------------------•-------•------ -- --•-------------------------------•--•----------•----•-------•-----=----•--•-----------------•----•------------------------------------------------- Fhereby certify that-I.have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State la and rules and regulations of the San Joaquin Local Health District. (Signed) ------ .. and/or Contractor) , r _ - BY= # - ------------------------------------------------------------------------------ (rifle)---- - -- ---------------- (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- ------ - ----- : - ------- ---- ------ ------------------------ ------------------------ DAT5--- ----= REVIEWED BY------------------------- ---- ------ --------- DATE--:--X-------- BUILDING PERMIT ISSUED---------------------- --------------------------------------=--------•-------. ------------- DATE..__ ------- Alterations and/or recommendations:------------•-----s--------------------------------------------••- = = - t ------------•----------•------------•-.------ ----------- ------------------ ' r i r ----------------------------- ---------------------------------,-----------------------------______________ __ _________________________________________ _ FINAL INSPECTION-' S i f � r - ------------------------- •----------- 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---•4-2M ; Revised W-2100