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APPLICATION FOR SANITATION PERMIT Permit No. .--------------------- e in (Complete Duplicate) f 3 - Date Issued ..�........ ......� Application 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 Ordinance No. S49. -e -------------------------------------------------------------------------------- JOB ADDRESS AND LOCATI N_...__-. �-_�`_ : -� -- ---- -------------------- -- Owner's Name ---------------- ------------------------------------- -------------- Address----------------------- ----0---- i' - ------------------------------------- Contractor's Name --------•--------------------------------------------------------------------------------=--- 0i`o e------------------•--------------- Installation will serve: Res&,rice N Apartment House ❑ Commercial E] Trailer Court ❑?'IVlotel ❑ Other ❑ l/ 1 % o G� Number of living units.. Number of bedrooms Number of baths ___`�Lotrsize _.. .._...x.............................................. Water Supply: Public system 'Community system ❑ Private ❑ Depth to Water able -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cay Loam ❑ Clay ❑ Adobe Hardpan E] Previous Application Made: Yes ❑, No 19 New Construction: Yes Q .m" lo ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: (� (No septic tank or cesspool permitted if`public sewer is avcable within 200 feet.) Septic Tank: Distance from nearest well-___--.'�____Di# nce from foundation_..___-�. r_.__-_.Material-----------_ No. of compartments-----*'�'^..-..-�-,5,'ize----_�} !_ - '; ------Liquid depth____`X-f--_-______.Capaci#y._.. - Disposal Field: Distance from nearest well_-- ._...Dunce from foundation-i__!____-_--.Distance to nearest lot line ...__.-. Number of lines-___---___`�_ Lang of each line------�J�C.. - ----.Width of trench---�-_-------------------------- / It i Type of filter material) . tt1 .Depth o filter material____��..'...._,._.___Total length..._' %�-............................. l 1 1 Seepage Pit: Distance to nearest w �.-__Distance fra foundation._____-___-_..Distance to nearest lot line---- of pits-- Z! its...... ..............Lining material___ __ ` --__.Size:'Diameter�aj_., � ' ...Dep#h----__-A�'------------------ Number Cesspool: Distance from arest well-----------------Distance from fou ation--------------------Lining material----___-____-__________-__--__-___. ❑ Size: DiamZolm --------------------------------------Depth---------------------------- -- ---------_Liquid Capacity----------------------------gals. Privy: Distance nearest well____________________________________-------------Distan from nearest building------------------------------------------ El ______-------_.- _______. ❑ Distance`to nearest lot line-------------------------------------------------R---------------- ----•--------------------------------------------------------------------- Remodeling i 1 and/or pairing (describe}---- ---------- -------------------------------------•-•------------------------------ ------------------------------------•--------------------------- r ' ------ ----------------------------------------- ------------------f--------------------------------------------------------•---------------------------------------------------------------------------- -------------------------------------------------- 1 hereby ertify that l have prepared this application and that the work will be done in accordah.ce with San Joaquin County ordinances, ate larys,rand rules and regul `ons of the San Joaquin Local Health district. (Owner and/or Contractor)(Si (Signed) :-I- --- ___--'_---__ ----------------------------------------------- By:By:-------------------- --------------------r-1----------------------------------------------------------------------------------(Title)--------------------------------------(Title)------------------ ------------------------------------------- I (Plot plan, showing size of lot, locatipn�of system in relation to wells, buildings, etc., can be placed on reverse side). ``�� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ ---------�-d I DATE------2--------f �-------------- Vr =- -------------------------------------- ---- DAT ---REVIEWED BY--------------------------- - ----------------- ----:-------------- ----------------------- --- -----•------------ ! BUILD€NG PERMIT ISSUED - ------- ---- - -- DATE------------------------------------------------------------- i Alterations and/or recommendations:____-. .."- ____ .�____--- -- ----- ------ ---- -- -- --- -------------------------------------------- ----- - ------------------------------------------------------ - --------------- -------------------------------------------------- - -- __ = `` --------------- 1 -kjo Date ----------- FINAL INSPECTION BY----- ------ - --------- -�--------- -------- - ,-- ------,------,:.�•-----�-� 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 7raey, California 1 ES-9----2M B-51 Revised W-2100 "