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APPLICATION FOR SANITATION PERMIT Permit No.,-,q-J_'_7----�� (Complete in Duplicate) Date Issued_ ------ -- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work h ein escribed. This application is made in compliance with County dinance No. 549. JOB ADDRESS __LOCATI _o--- ,� . - -------------------------------------------------------------------------------------------------------- Owner's Name--- V ----- ----- ------------------- ------•------------------------------------------------------------------------- Phone--------- —- Address-... --------�1 --- `- - - - - - ---------------------------------------------------------------- Contractor's Name-----_------------------------ -----------------------7------------------------------------------------------------------------------------ Phone-------------------------_-------- Installation will serve: Residence [ partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other E]Number of living units: - ) Number of bedrooms ----- _ Number of baths ----/-__ Lot size -_--�1-_ q_6----------------____-----_ Water. Supply: Public system Community system -.E3 Private E] Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand E El Sandy Loam Clay Loam ❑ Clay E] Adobe�ardpan Previous Application Made: Yes ❑ No V New Construction: Yes Lo;?o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: R` por if � ewer is available within 200 feet.) Se tic (No aokseptic tank tancesfPomlearest wel -P�-7-l� il' Dista cel fro rfoundaion---------- _____Mai rirl------______________________ __________ No. of compartments------ ------�,c_______Size_�__K_ q p P y ,�� ! �_ �(�� XA ..Li ufd depth h--------- ----------------Ca acct - -- -- ---�--� Dispos 1 Field: Distance from nearest well--- _1k1_f 'Distance from foundation_____�_Q_ -_-Distance to nearest lot lin [ Number of lines______________ N3_-___ -Length of each line------------- ef____.Width of trench_______�_7" 1 f�* of filter maten�l_,___ +_ ___ __ _____ epth of filter material______1--(J-__- Total length___________0- ----------------------- Type Seepage Pit: Distance to nearest,well----------------------Distance from foundation---------------------Distance to nearest lot line____--_--______ ❑ Number of pifs----------------------Lining material----_------------------Size. Diameter------------------------Dept h-----------------------.--------- Cesspool: Distance from nearest well-----------------Distance from foundafion-.:__'______-"-----Linin g material___________-_______________________. ❑ Size: Diameter--------------------------------------Depth----------- --------------------------------=-------Liquid Capacity_. ------......-.---------•gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------- ❑ Distance to nearest ]of line__________________________ _____ �.Y 1 ' Remodelin and/or repairing describe _____________________ - ----------------------------------------•--------•------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------•-------------•-.------------------ ------------------------------------------------- -------------------------------------------------------------------------•-•--------------------------------------------------------------- -----------------------•------------ -------•-•-------------------- 1 hereby certify that I have prepared this application and that the work will be done iii a cordance with San Joaquin County 3 ordinances, S aws, and rules and LMrealions of the San Joaquin Local Health District. C i [Signed)- Owner and/or Contractor ------------ [ ) By------- ------ ------------------------------------------•---------------------=-----------------------------------------------(Title)-------------------- ------------------------------------------- (Plot plan, showing si of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). { I FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY__ DATE_�--______________------------------------------- _____----------------------------- REVIEWED BY---------------------- --- - ---- ----------------------------- DATE BUILDING PERMITISSUED------------------------------ ----------------------------------------------------------------------- DATE Altera ' s and/or reco mendations!---°•---------•- ------/? =--- ------• - --------------- �� - - • ---- ----- ,/c •_ t ------------------ - -- ------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------ ----------------------------------------------------------------------------------------•-------••----------- FINAL INSPECTION BY:----- ----- ------------------------------------ Date-------- --------------------- 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-4-2M 9-51 Revised W-2100