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APPLICATION FOR SANITATION PERMIT Permit No. . ................ (Complete in Duplicate) l� Date Issued .__,l _ _�``_____ Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here' described. This application is made in compliance with County Ordinance No. 549. � „-71- /11-1 JOB ADDRESS AND L CATION__ oM€ _it1 _ �"`"f , "``� + -------------------------- -------- -------------------1�±-—----------- Owner's Name________ _ _______ __ Address-----------------------•--_ l �-� Con#ractor's Name _ -------------- Phone------...7 v4t-6-Q 7---- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ !Motel ❑ Other ❑ Number of living units: ___I__ Number of bedrooms __Number of baths ---L Lot size ___,�7__Q_� ._._/_O_Q_---____-__-_-_--__ Water Supply: Public system ❑ Community system ;R� Private ❑ Depth to Water Tableft. Character of soil to.a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeM Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑ "'L -- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S pt.c Tank: Distance from nearest well-_______________Distance from foundation--------------------Material_______________-__.__----_____________-_______- IF>d No. of compartments------ -------------------Size--------------------------------Liquid depth-------------------------.Capacity----------------------- D' osal ield,: li Distance from nearest well_________________Distance from foundation.-------------------Distance to nearest lot line.-____________--_ Number of lines-----------------------------------Length of each line-----------------------------.Width of trench----------------------------------- [[[ Type of filter material_________________________Depth of filter material----------------------- length-------._--____________________.______-__ See age Pit: Distance to nearest welL_�s�_�G r__Distance fr f�}undation—+ ._..Distance to nearest lot line___ ------- , - Number of pits______.____-_____Lini g matorial.�l�tA JS�__.Size: Diameter_.,��_11-..____Depth. , ._______________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----_-__..____.____.____-___.______ ❑ Size: Diameter-------------------------------------Depth----------------------------------------------- --Liquid Capacity----------------------------gals. Privy: Distance from nearest well____ _____-_.__________._Distance from nearest building_________________________________________ • ❑ Distance to nearest lot line---------------------------------- ---------- - ---------------------------------------------------------•------------------------------------ Remodeling and/or repairing (describe):------------------------------------------------------------------------------------------------------------------------------------------------------- •------------------------------------------------•-------------------- ----------------------------••-------••---------------------------------•--------------------------------------------------•----------------------- --------------•-------------------------------------------•---------------------------------------------------------------------------------•-------------------------•------•-----------•------------------------------ I hereby ce ".,narepa.e this application and that the work will be done in accordance with San Joaquin County ordinances, Stat and a ulations of the San Joaquin Local Health District. (Signed)---- ---•---- - ------ ------ -------C�_ --------------- ------- -------- ------ -- -- ------------------ Z ------ - Cant actor) By: -- {Title) -'�----- - - -- ------------- (Plot plan, showing size of lot, location of system in relatio to wells, buildings, et , can be pon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- - - 4- ----------------•-----••--•-----------------------._-_ DATE----------- REVIEWEDBY------------ ------------------------------- -------------------------------------------------------------------------------- DATE--------------------•--•- BUILDING PERMIT ISSUED----------------------------------------------------------------------------•------------------------ DATE----- Alterationsand/or recommendations:-- ----------------------------------------------------------------------------•-•--•-------------•------------------...-------•------•---------•--•---------- -----•--------- ---------- ---------------------------•-------------------------------------- ----------- --------------------------------------------••----------•---------------------------...--•-•--------------------------•------------- ------------------------------------•--•------- --------------------------------------••-------------- ----------------------------------------------•------------------------------------------------------- -------------------------------------------------------- ---------------------------------------------------- -------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:.---------- -•-------- ------- Date-----------------�� -------------f------ ---------------------------- 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-9-2M ; Revised W-2100 t�