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1 APPLICATION FOR SANITATION PERMIT Permit No. a.-i(o--- - .� (Complete in Duplicate) Date Issued �f/ S_-- u A lice#ion is here"y made to the San Joaquin Local Health District for a permit to construct and instal] the work herein described. ' PP This application is made in compliance with County Ordinanc"o. S4,.--, 5, a -------------------------- JOB ADDRESS A D LOCATIONS-1, -!"' ~ o' ----- - - Owner's Name- --------- -- "'-- -�- -----• ---- ------ ---------- ----- Phone-----'-�"�'-------------------- i--------- ---- ----- ---- ------" �----;------------------ f Address------------ ' =•� --------;-•----•-------- -- -- -------------- -----------------------------------------------•-------------------- Phone--------------------- =- --------- Contractor's Name --- -------------------------------------------------------------------- ! -- .--- -------- + .1 , Motel P Oth r Installation will serve: Residence ❑ Apartment House Commercial ❑ Tt Court ❑ Number of living uni#s: "" umber of bedrooms ____ -" Number of baths Lot size .__ __ __-- ------------------- Number --- - Water Supply: Public system Community system [] Private ❑ Depth to Water Table -------- ft. eet: Sand Gravel ❑ Sandy Lo;reoNo Clay Loam ❑ Clay ❑ Adobe 5r/Hardpan ❑ Character of soil to a depth of 3 f � Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION ANA SPECIFICATIONS: 1 (No septic tank or cesspool permitted if public se er is available within 200 fe,pet.))j -A istance fro joun attion____L-49------.M t ri L_____"_"_-- - "-------- -- - Septic Tank: Distance from nearest well___ _ -- Li uid de th_____ ----------Capacity___ -------- No. of compartments-------� - - -------- izer - --- d p{" Dis os 1 field: Distance from near st Weil---- _Distance from foundation__ _"l_ Distance to nearest lot lin r ______ --- &- 0 _ .Width of,trench____ " Number"of fines_______ Length of each line_______" . - -1 .. f`""" s e th of filter material -:1 -____-Total length------------ ----- ------------ 4 ------•-•- = R Type of filter materi P 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__'____^-�:n_-_Distance from foundat.ion---_-_.__".--______-Lining material______________________"__-_-----ale. t ❑ Depth---------------------------------- Liquid Capacity---------------------. g Size: Diameter-------------------------------------- Privy: Distance from nearest well-___-__---------------------•------------- - Distance from nearest building___________________________________--___". ❑ ---------------------------------------------- - Distance to nearest lot line--- --------=--------- -------------------- -------''-----------• ...------•-••-----------••------------------ "��► . Remodeiing and/or repairing (describe):------------------------------------------------------------ ------------------------- ----------------- -----------------------•------•-------- -•-- ------------------------ San I hereby certifred t y that li have ppareh --- is application -a- d that the work will be done in accordance with San Joaquin County ordinances, StaTe.laws, and rule and regulations of the Sar► .Joaquin Local Health District. I; (Signed)----- � � - ` ----------------------------------------- ---------------(Owner and/or Contractor) ::s ------- 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 I `, DATE--- - APPLICATION ACCEPTED BY---- ------- ----------- --------------------- _ DATE -----�------------------•-------------------------- REVIEWED BY k BUILDING PERMIT ISSUED--------------------------- --------------------------------------- DATE- ---- /7it atl s and/or com endations-- -------- ------ ---- :---------- --------------------------------- Y ---•-------------------------- r - - f 3 -`- ---' ----------- ------------------- --------------------------- ------------------- I -------------------- ------------------------------ FINAL ..- ate-------; FINAL INSPECTION BY:__.-- --""-- - -- --= --=�"----------- -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Sfree+ 814 North "C" Street 130 South American Street Tree California Stockton, California Lodi, California Manteca, California y, ES-9-2M S-SI Revised W-2100