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APPLICATION FOR SANITATION PERMIT Permit No. ...... .. ... /V (Complete in Duplicate) Date Issued ___ PP A lira{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install hey work herein described. y This application is made in compliance with County Ordinance No. �549^� �" MeigQ G `d!`-. �.. wT-".� Y�,, �„�'----''�-� JOB ADDRESS AND LOCAT,ION_______________- !!Y_ Owner's Named_5.., _!... __ Lfi X-_t-- -------------------------------------- Phone-------------- ---------------- ( s 'c "' =--------------------------------------- --•---------------------------------- Address _ _-€,� ._ .Contractor's Name__ : -------------------------------------------- -------------------------------------------------- Phone..--------------------------------- Installation will serve: Residence- M/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Number of living units: _'. __ Number of bedrooms .. _ Number of baths __/..__ Lot size ---- _ `.`_X__11 .__--- Water Supply: Public system v Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam E] Clay Loam E] Clay E] Adobe 2/HardpanE]Previous Application Made: Yes [j No New Construction: Yes R"'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 244 feet n.) � � E Septic ank: Distance from nearest well. L_ -------Distarc from fountion---- !!----------Material ------------------____--_____.,P.-- No. of compartments.______. ..____._.__Size- __ `_ __ -----Liquid {{depth_=___ _ " _ ---------Capacity.___� ----y�__ Dispos Meld: Distance from nearest well_ r__._..._Distance from foundation_ I��tance to nearest to line_,_._- -_ . Length of line____:_ ._ [�� Number of lines--------- -----4Z -__ I� Width of trench---____-- -'--`"£.---- g q� Type of filter materi 411,1_ 14—bepth of'filter material-_ ___._--.Total length--------------/-__�+_ __.__----..__.- 1� YP r=-f ,- "Seepage Pit: Distance to nearest well______________ ______Distance from foundation--------------------Distance to nearest lot line----------------- � ❑ Number of pits------------=------- Lining material---------.-------------Size: Diameter----------------------Depth------------------------------ Cesspool: Distance from nearest well_________________Distance from foundation------------------- material-------------------------------------- ❑ Size: Diameter--------------------------------- ----Depth-------------------------.----------------------------Liquid Capacity---------------------------•gals. Privy: Distance from nearest well--------------------------'--------"-------;-- Distance from nearest building-----------------------------------_-----. ❑ Distance to nearest lot Iine-------------------------- ----------------------------------- --------I--------------------------------------------------------------------- 4 R mod line' and/or repa' i l� X(d scribe) j - :• --------• -- . .. -- -------- ----._. .-'_ -----------------••------------------ ---•-----------------------------------------------------------------------..-.------------------------------------- -------------------------•------------------------------- ----------------- ------------------------ -----------•-•-•---•-•----------------------------------------•----•-----------------•--------------- ------------------------•-•-----------•------------------------- I hereby certify that I have prepared 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. _______________________________.__(Owner and/or Contractor) (Signed) F ti k. t By:.... -------------------------- {Title) --•-•------------=----- (Plot plan. showing size of lot, location of system in relation to wel[s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. - DATE -- ------------------------ --• -------------------- REVIEWEDBY------------------------------- --- ---- --------- ------------ -------------- -- ------------------------• DATE-- �,lk--------------•----------- --------------- BUILDINGPERMIT ISSUED-------------------------------------------------------•--------------------------------------------- DATE__-n ►---- ---------------------- - ------_---------- A Alterations and/:o� recommendations:_--• ---��--.--------1�._�----------e----_------ --- E `� J1 '� r _' ----------- .. • •a '�'' ----------- --- --------------► ' -------------- ----------- :---------------------------------------------------------- ---------- --------- n ------------------------ ------------------------------------------ ..SAT--- �/-/-s� �,lt • �+�'°�-u.uJ d - .� c"c.z't"e' �-`�`�' Cr�c� � ® � r�J�-'�--ray �+t� �c.Q1L FINAL INSPECTION �_� _ �_� ------------------------ Date.----- T 5 ----------------------------------•---- BY:-_-.._ . aSAN 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.r:_i � E5-9 iasaas arwoo❑ 7 (/�'? /� �J/.�Je��- F'' � � e, 1 L