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, . /, APPLICATION FOR SANITATION PERMIT Permit No. I (Complete in 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 Co my O dinance No. 549. ' JOB ADDRESS AND LOCATION.. -------------- ------------ /? . -------------------------------------------------------------------------------------------- Owner s --------------------------------------- Owner's Nam ` - Phone.--------•----------••---•-----•---- Address----------- =------ -- -- -f-- --------- ---- ------ --•-------------------------------------------- ---------------------------------------------------------------------------------------- Contractor's Name----- -------- ------- - ---------------------•-----------------------------------------------------------•-------------------------------- Phone------•---------------------------- Insfalla+ion will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Mot l E] Other E]Number of living units: __fNumber of bedrooms ---X Number of baths .1------Lot size c+ _g _� *�----------------------- li Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a{depth of 3 feet: Sand Gravel ❑ Sandy LClay Loam ❑ Clay F] Adobe �rdpan ❑ Previous Application Made: Yes E] No New Construction: Yesoam No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted i ublic se)ver is available within 200 feet ` ! els Septic Tank: Distance from nearest well--_p__no 141Distan effro ou -. tion-�Q._.-..-_._..Matera�______________________________ ____.__--_.--. No. of compartments------- -- ----------Size-- - - _Liquid dept ----- -- ------------Capacity --- - -- ' Dispos f"Field: Distance from nearest well___ ., istance from foundation -Distance to nearest lot lin ___ 5_._!!*"r�'+ -.i I Number or lines_________ _ _____ __ _ _________Length of each line--_-------._ �_ _ _. Width of trench___._____ -___ ,'Type of filter materi -_-_ _ .:_-_ yp ' ...._----- epth of filter material---------- - ._---Total length------------------ - --------------- 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--------------t__Distance from foundation---------------------Lining material-_____----.__--._._.--._----_-.------. cl ElSize: Diameter--------------- -----------------! Depth---- --------------------7- ---- -------- --------Liquid Capacity------------------------------gals. Privy: Distance from nearest well__-.--._...__f----------------------------------Distance from nearest building-.------_----_.------_-__---_.--._----_-. �v} ❑ Distance to nearest lot.line'------------ ------------------------------------------------------------ ---- ------------------------------ i Rmodeli and/ . rep r n (des 'be' y -------------------`--------------------------------------------------------------------------------------.........------------------------------- aw'E � i i E -----------------------------------•-•----•-------•-------------------------••----------------------. ---- ........ -- Y y ---------------------------------- — - -- ---------•--------------------- ` ------------------------- --- ------------------------------'------------------•-t---------------- -----------•--------------------------------------------------------••------------------------------ -------- I ereby certify that I have prepared this application and +hat the work will be done in accordance with San Joaquin County ordinances, Sfafelaws, and rules and reg afions of fhe,San Joaquin Local Health District. l (Signed)----- 4j,1, _ ...... -4` �' -------- -------------------------------------------------------------(Owner and/or Contractor) , By:-----------------------------------•---.------•-------- I------------------ i--------------------------•----------------------------(Title)------------•--------------------------------------------------- (Plot plan, showing size of lot, location of sysfem in relation to wells, buildings, etc., can"be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ------------------•-•------------ DATE-.�-----------•----- •------•-•-••----••------••-•---- REVIEWEDBY----------------- --------------------------•-------------------•-------------- ----- DATE--- ---------------------------- -------------------- BUILDING PERMIT ISSUED-------------------------- ------------------------------- ---------------------- ------ ----- DATE -- -------------- -- ------------- -- Alteratio and/or recommen ations:___ ._af7.f�- - --- -•---- ----- ,. ----------------------------------------------- ------------------- ------------------•----------------•--- --------------- - ------- ------------------------------------------------------------------------- ---------- --------- -- •---------------------------------------- I --------------------------•--------------------------------------------------------------------•...--------------•-------------------------I-------------- -------------------•-----------•-----------•--11-------•--'-------- FINAL INSPECTION BY:_. ---_ Date--- - --"__'_ ----------------------------------- SA 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 145446 ATWOOO 1Z-54