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APPLICATION FOR SANITATION PERMIT Permit No. •_ ., -;Ls (Complete in Duplicate) Date Issued q-/_5-'Y,3 Application is hereby made to the San Joaquin Local Health District for a permit to construct and i all the work herein described. This application is made in compliance with Cou*c, . 549. , /�o JOB ADDRESS AND L CATION J ) C1/ I✓ 1y�a r ---- -- ------- - - �-- --------- 4?_lE? l�c rtOwner's Name- ------ •--• -- - -•+----•- - -• - -- _ -- ------ - - •-Address._. tl ..�Contractor's Name .. _ ..- ---... --- ------------------ Phone = Installation will serve: Residence Apa ment House ❑ Commercial ❑ Trailer Court ❑ Motel Other Number of living units: _';e Number of bedrooms - Number of baths Lot size ___ ___. Water Supply: Public system ❑ Community system ❑ Privat% Depth to Water Table . __�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe IV Hardpan Previous Application Made, Yes ❑ No X New Construction: Yes N . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wit i,0200 fe .j Sept' Tank: k Distance from nearest well_/M_�-Distanc fro',f u d��jjtion____�_ot_---___.Materi I______ _ _______ -------------- --- X o. of compartments------------ Size-3- —Liquid depth_.______." ___..___._Capacity___ __Z --- Disposal istance from nearest well___f_40.iDistance from foundation___._- _Distance to nearest lot li e-_� �____- umber of lines..._-._.- •. ..•----------- -----Length of each line_____8Q_____DD___ti-------Width of trench-------Z-�---_-------_------- Type of filter material.-St�----Depth of filter materiaL____1_�i--------._-Total length--------$_e.Q'_________________________ 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-----------------Distance from foundation--------------------Lining material_.______._..__________.________---__ ❑' Size: Diameter--------------------T---------------Depth...-------------------,-----------------------------Liquid Capacity--------- -------gals. Privy: Distance from nearest well_____________________________--------------------Distance from nearest building-------------_-______________-_____-_-... ' ❑ Distance to nearest lot line---------------------------------------------------------------------•----------------------------------------------------------------------- Remodelin an /or repa• ' g { e tribe):- ------------------ rxe- ► , i --r-- r l , �-r--------- ie► s.•L. y ---- --- --- - --•-'------- ----- I hereby certify that I have prepare his application and that the rkCard ce Coun ordinances, Stat laws, and rules and regulations of the San Joaquin Local Healt District. �' + --------------------------------------------------------- ------(Owner and/or Contractor) BY:--•---------------------------------------------------------------------------------- ------------__---------------------------_(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------------------ ---------------------------------- ----------------------- DATE---------------------- - ------------- REVIEWEDBY---------------------------------------------------------- -------- ----------------------- DATE----- - --_1---t__ ----------------_----------- BUILDING PERMIT ISSUED------------------------------------- ------ --- DATE Altera ions and/or r cQmme ations: f F o ------- --- -- - - • -•-- -•- • --�. - S.C. et. ----------•------------- - {�"'"`-------- •- � -------------------------------------- --------------•--------------- ----------------------•---•--------------------------•----------------------------------------------------------------------------------------------- -------------------------------------- --------- ---------------- • -------------------------------------------------------------------- --------------------------------- 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 E5--4-2M 10-52 Revised W-2100 1 G'!r v X.I