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APPLICATION FOR SANITATION PERMIT Permit No., -.f_.....___? (Complete 1n Duplicate) Date Issued ____ __!-.._._____--� 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 Or finance No. 549. JOB ADDRESS AIGATION_._. !_ _. - 6 � �^ r ------- --------------------•------------------------------ Owner's Name- ------- ��/�,�.�----�--- ''c `---------------- ---------------------------------- Phorre��°. 7 Address------------ - ------ ------------------ a % Contractor's Name__:_�JC/f f-/7� Pho tQ- ��-� Installation will serve: Residence Apartment House E] Commercial [-]Trailer Court F] Motel El Other E]Number of living units: Number of bedrooms y__ Number of baths I--- Lot size_r------� Water Supply: Public system' Community system ❑ Private ❑ Depth to Water TablePft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam j] Clay ❑ Adobes/ Hardpan ❑ Previous Application Made: Yes ❑ No b( New Construction: Yes ❑ No ❑,OpPp�c°%��d7 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �c Tan l Distance from nearest well ----------------- Distance from foundation --------- ._-_-:----- Material _________-_.--_____---__.____________________- / No. of compartments -------------------------- Size ------------•--•---------------- Liquid depth -------------------------- Capacity ....------------------- Di sa di Distance from nearest well -------------_-_.Distance from foundation __________---------- Distance to nearest lot line ----------------- <- q ®'# j Number of lines---------------------------------- Length of each line ------------------------------ Width of trench ----------------------------------- 6 Type or filter material ---------- _-------------- Depth of filter material ----------------------- Total length ------------------------------------------ 0 y / ' kn Seepage Pit: Distance to neare t welAO-46 --------- Distance fut f undation__I-____.-..___.Distanrrye to nearest lot line__o`h--._____ Number of pits ---- I ________________ Lining material _ - °i"`��___.Size: Diameter.. --3-.3--- ----- Depth_. �_.____-__-----__-- Cesspool: Distance from nearest weld ----------------- Distance from foundation ---z______.___.---.Lining material ------------------------------------- El Size: Diameter----------------- -------- ---..Depth---------------------------------------------------- Liquid Capacity- ------ -------------------gals. 0 Privy: Distance from nearest well --------------=--.---____________---________.._._Distance from nearest building -------__---_-_______________.______-_-.. ❑ Distance to nearest lot line ------------- ------------------------------------------------------------------------------------------------------------------------------ Remodeling and/or repairing {describe): --------- ---------------------------------------- --------------- ------- '"�` Y --------------•=--------,----------------------------- I hereby certify tha I have prepared this applicati4 ordinances, Sta+ aws;�nl rule';and� egulations of the (Signed)--------- By-------------------------------------------------------------------------------- (Plot plan, showing size of lot, location of system in. rel FOR ------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------- --------------------- ind that the work will be done in accordance with San Joaquin County h Joaquin Local H-ealth District. . If ------------------- {. Contractor) `� . (Title)- - 'S,- ------------------ to wells, buildings, a ., can be placed on reverse side). ARTMENT USE ONLY • APPLICATION ACCEPTED BY DATE__�------------------------- •----------•-------- REVIEWEDBY ------------------------------ -------------------------------------------------------------------------------- DATE___.�_—o ---------------- PERMITISSUED ------------------------------------------------------------------------------------------------------ DATE ---------- Alterationsand/or recommendations: --------------------------------------------------------------------------- ---------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- -------------------•---------------------------------------------------------------- ------------------------------------------------------.---------------------------------------------------------------------- -------------------- ------- --------------------------------------------- ------------------------------- ------------------------ ----------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------------- 1!•- 7e �----- Date-- ------ �----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stree�`" 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, Califyrnia Lodi, California Manteca, California Tracy, California ES -9-2M Revised W-2100