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J i t � APPLICATION FOR SANITATION PERMIT Perm No. (Complete in Duplicate) Date Issued Applical-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 Ordinance No. 549. s � JOB ADDRESS ODLO ATI ---- `� c � -�-- �.._.��l- t�t ------- � - Owner's Name :' w = i ------------- Phdne-------------_ p. _---------- ------------- Address------------ ----�--- --- -- --.- r .�.-ems __ `�--------------------------------------------------------------------------------- --------------•---- ;1 Contractor's Name--- ------- ------••-------- ---•---•------------------ ------------ ----------------------------------------------------- Phone Insfallation"will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _-- _--- Number of bedrooms .154 Number f baths ---i--- Lot size -1Z5--- _.--____ __Z6 -- Water.Supply: Public system ❑� -Community system [-1PrivateDepth to Water Table .-_..-._ ft. Character of soil-fo a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ .Clay Loam ❑ Clay ❑ Adobe MeeHardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fank.or cesspool permitted if public sewer is available within 200 feet.) Se F&Tank: Distance from nearest well_________________Distance from foundation------------------- Material------------------------------------------------- No. of.compartments---------------------------Size---------------•----'----- ---Liquid depth--------------------------Capacity----------------`---- Dispos `Field. Distance from nearest well._ Ya__-----.Distance from foundation-__/?____.__.__Distance to nearest lot Number of lines----------------(-------------------Length of each line---------�---------------Width of trench---------��/'--------------- r Type of=filter material------I. �_---....__Depth of filter material____._/- ----------- otal length-----------��____________________a: W Seepage Pit: " "Dist ance-to"nearest well':`__ _ __ :Distance from foundation-------------------Distance to"nearest lot line----------------- N ❑ Number of pits------- --------------Lining material-----------------------Size:. Diameter------------------___-.Depth--.--------------------------__-- Cesspool: Distance from nearest well-.,--,------------Distance from foundation---.----------------Lining material-------------------------------------- `'11. ❑ Size: Diameter----------------- --------------.-Depth------------------`---------------------------------Liquid Capacity----------------------------gals. ' Privy:, Distance from nearest:well-_______________________________________---------Distance from nearest building------------------------------------------ .—Distance --_---__--_•-------__________-_----_--_.•—Distance-to•nearest lot line-- .--- --------------•---------------r-------•---------- - -- Remodeling and/or repairing (describe)---------------- -------- b �.y - --------- ----�e1 --- ------------------------------------•----- - r ----------------------------------- I---------------------- ----------------------------------------------------------------------------------- - ----------------------------- --.--.--.--.--.-.- -.-.-.-.-.-.- ------------------------------------- f . : 1 L hereby.cerfify Aaf I have prepared this application and that the work will be-done in accordance with San Joaquin County ordinances, State laws,;and Pules and regulations of the San Joaquin Local Health District. (Signed) I!�'L_� Lf::: � i ---------------- :--------- --:--------------- -------------------------------(Owner and/or Contractor) / ../ . .,,. ----- Title Plo# Ian, showing size of to+,'location of system in relation SY= -- ----• - ----- -- ----•-•--------- (Title) ( p g y ion fo wells, buildings, etc., can be placed on reverse side). -' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�.___.._._---. , ------------------------------------- T--9----------------------------------- DATE------------c'"-�yl�----' �"�------------- REVIEWEDBY-----------------------------------------`----------------'------•--- --------------------------------------- ------------ DATE------------------- BUILDINGPERMIT ISSUED--------------------------------------------- '--------------------------------------------------- DATE-------- ---•-- ------- Alterations and/or_recommendations:--- -------- -------- ------ ----------------------------------------------------------------- -------------------------------------------- -----------------------------•---------------- ---------- -------------I-------------------------------•-------- ----------------------------------•---------------•--------------------------------------- ---------------------------------------- -------------------------•--------------•----=-------------------------------I——------------------------------------------------------------------------------------------------ ---------- ----------•----•--•------------- ----------•------------------------------------- ---------------------------------------------------------- ----------- ---------------------•----------------------------------- s 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--9-2M Revised W-2100