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APPLICATION FOR SANITATION PERMIT Permit No. ._. (Complete in Duplicate) / C Date Issued --- ------ --___-J Application is h reby 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 Or finance No. 549, i r JOB ADDRESS AND LOCATION._.._�5-- r Owner's Name------/:`/ - --------------- -------------------------- Phone---�_ fir--30-4------- Address.. ----------------- ------ -- �/ ------------------- Contractor's Name_ - ---- ---- - ----••-•- --------- Phone--- � ------------- � Installation will serve: Residence CR Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I-_ Number of bedrooms -A- Number of baths ---_____ Lot size ____rj' ___ � a S -- ------------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Iy4_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeW Hardpan ❑ Previous Application Made: Yes ❑ No ;K New Construction: Yes ❑ No�( TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) -Caef4 ir Tank: Distance from nearest well-----------------Distance from foundation--------------------Material----------------------------------------------- No. of compartments--------------------1--- - -Size---------------------•--•-------Liquiid pth--------------- --------..Capacity------------------ Disposal ie ._. Id: Distance from nearest well_. -- --.-.-Distance from foundation--- --------Distance to nearest lot I Number of lines----__ --5--�--G______Length of each line--- R-47 Width ofgtrench-------� -----� I ------ Type of filter matenaL____�__ �___ __De th of filter material_-__-- ---------_--Total len th_______________________.__-3�--�_--� , • r Seepage Pit: Distance to nearest well._.__ _Q.______Distance from foundation___ _____________Distan�7 to nearest lot line--- _______.___.__ Number of pits------/------------Lining material Size: Diameter__..___6---------Depth-- Cesspool: epth Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material________-_____.._______._________ " ❑ Size: Diameter--------------------------------------Depth------ ----------------------- ------------------ --Liquid Capacity- --------------- ----r-----gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------._-_-.-.-._. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------- Wt, Remodeling and/or repairing (describe):_zz.__ -- ---:------ ( i -------------- - f - I - - - -- ------ + " ----- - _- d ..... .. _ ___ _ ___ _�e---------�-- ---•___ _________ --------------------- _ __------------------- ------ _ ____________ - k Tp, .r,.d ---------------------------------------- -----------------------------------=----------------------------------•---------------- fiereby certify that I ave 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. ' f ----------- ----- - - --- - - -- *spt;em - -----{ weer and/or Contractor) (Signed) _____ - Title -------------- Y� { ) (Plot plan, showing size of lot, location in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY III APPLICATION ACCEPTED BY---- --------------------------------=-----------------{��r- �-f----------------------------- DATE------------�.�j---..�.----=- �-�------------ REVIEWEDBY------------------------------------------------------------------- ---------------------------------------------------------- DATE------------------------ BUILDINGPERMIT ISSUED--------------------------------------------------------------- ------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations:-------------------------------------------------------------------------------------------------------------------..__.---------------------------------------- ------------------------------------------------------------------------------------------ ---------------------------------------•---- -•----------------------------------------- ---------------------------------------------------------- -------------------------------------•--------------------------------- ----------------- ------- ---- - -------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------- FINAL INSPECTION BY---------------1/_.__.�y� _�--------- Date------------------------------------------------------------------------------- SAN --------------------. -- --------- ------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I ES-9-2M 10-52 Revised W-21 D0