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CAMtK APPLICATION FOR SANITATION PERMIT ° Permit No. --------- ----- ,,�C.�r,� � ,�.tJ L•+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 w- County Ordinance No. 549. JOB ADDRESS AND L0 TIO ___- _____ __ ______ - - ------ - Owner's Name-- ----- - ---- -- _..... f ----- --------- ------------------------------- ----r=- -- Phone----------------------------------- ------------- Address ------- •-------------_--Address ---------- - --------a....... -•- - --------------------- - -------- - --- - • - =----- _-- - -----Contractor's Name---------------,Q--Z'i------f- ---------- - -- -------- --------------- ------- --•- ---- - -- Phone. _......................... Installation will serve: Residence 4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Fi Number of living units: -I___ Number of bedrooms I-___ Number of baths __/___ Lot size__-__ _A___:L00_______ _______._._... Water Supply: Public system ❑ Community system ❑ Private Dq Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam❑ Clay ❑ Adobe Hardpan ❑` PreviousApplication Made: Yes ❑' No New Construction: Yes No TYPE OF INSTALLATION`AND SPECIFICATIONS: , (No septic tank or cesspool permitted if public serer is available within 200 feet.) Septic Tank: Distance from nearest well *QQ Didtancp rom f tedation__/ __.Maatprpl _ No. of compartments-----•-2--- ----- Size.-#09(-- --------Liquid depth--=---*----------------Capaci't'y-- - ------ Disposal Field: Distance from nearest well ®D__Distance from foundation __-Distance to nearest lot 141n f0 Number of lines-__ Length of each line -____ Tf Width of trench.. `- __ Type of filter material,-__��1- Depth of filter material-_____.j_�_____-__Total length________________&_f�----------------- Seepage --__._______,_Seepage Pit: Distance to nearest well _________________Distance from foundation................... to nearest lot line............... :_- ❑ Number of pits_,-- ---------Lining material------------------------Size: Diameter...--------------------Depth_------------------7--,---_-- Cesspool: Distance from nearest well............. Distance from foundation_,_._.<.._._..___.Lining material-------------------------------------- Size: -_ __---____ _________________.Size: Diameter----- --------- ---------Depth------------------............_ ---------.0 uid Capacity------------ _,gals., Privy: Distance from nearest well_________ __-------------- - ___ ___---_Distance from nearest building------------------------------------------ ❑ Distance to nearest lot line---- ------------------ - ------ -- ----- ------ ........ Remodeling and/or repairing (describe) -.1 .G " -_....+.._`"-t-..�r-+ ... ..............rte t ................................................................................................fl-....7---- ---------------------------------------------------------------------------------- .........4........ �. ------------------------------------I...................-------------------------------------------------------------------.........---------------------------------------------I................. --------------- - -- --- -- ------- ------- •------- -------- -------- ------ ------- -----• - ------ ----- ------- _- -- -•---- ------- - ---- ._................. I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Staf I an rul gulations of the an Joaquin Local He Ith Di' rict. - -------------- , (Signed)..... .. - --- ------- -•(Owner and/or Contractor) B ----- --------- ------- -------- ------ ------------------- ----- - -- ---------------(Title..........---- ------- ------ - - -- -------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY -_ _ 1_ DATE_ / ^" • REVIEWEDBY----------------------------------------- - - --------------------------------- ----- -------- ---------: DATE_._,Z; -----------. -7-------- -_-- ------•- BUILDING PERMIT ISSUED----------------------- __ --.......... D D TE-- Alt pati s nd or reco a t� ns._-_ C_ � .. -- - ---- - 7- - � '/t�-�-,---- - - d- - 'z-------- - -- - O �. - ______ !� --------------__---------- ___.___-_ '________ _-_____-------------------------- --_-___ ______-___..._-_.. FINAL INSPECTION BY-------- ----- --------- ....... - Date-----------------... - ----•-- ------------------------................. SAN JOAQUIN.LOCAL HEALTH DISTRICT 4: . 130 South American'Street 300 West Oak Street 132 Sycamore Street 814 North "C" Str"t Stockton, California Codi, California Manteca, California - Tracy, California ES-9-2M 8-51 Revised W-2100 f.;