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� 1 .� � � �,,/\ � 1 �� -•- ��... � APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date issue �pp Ica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein scribed.L This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------- - ----- -------- -------------- -.-- �`=--_-- ��../I ----- Owners Name------- ------ --- --- -------------- = =-------------------------------- --------------------------------------------- Phone--�� ? ----- I. Address. i_ -------------------------------------------------------------------------------------------------------------------------- y-�.� Contractor's Name------ --- --- - •• _ :. _>------ `�'~` T°"_'` Phone ��-d - ------ Installation will serve: -Residence B-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units /--- Number of bedrooms .--;k-Number of baths--4_ Lot-size ----- 424------------------------ r Water Supply: Public!system; 1pCommunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: .Sand ❑ Gravel ❑ Sandy Loam ❑ l Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: .Yes ❑ No [B-"-New Construction: Yes B-`�o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: .,.1 # (No septic tank or cesspool P_ -a if public sewer is available within 200 feet.) Septic T i Distance from nearest well m Distance tofou d --/-- ation_ 4-------.Ma#erialr---------_- No. of co P___`r:--.-Size mpartments_-------- ___ _,_'Liquid depth----- - -----------Capacity Disposal Id: Distance from nearest well-001 ----Distance from foundafion---R4- -_----Distance to nearest lot line---------- _ Number of lineA------------ - ----------Length of each line---------3a_�---:_---.-.Width of french------ay-�r-----_____---_- Type of]filter material---;Fi"?o A---Depth lof filter maferial length----------34-- _____._.-------- See pag i : Distanceto nearest well--------J'y----- ----Distance from foundation........._'o•._......Dsstancg to nearest lot line -� ; - pe , Diameter------$�-� Depth -------- Numberg:of pits"--= _-.--_---..Lining. matenalh •C�O -e- p ' ---------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------_-__-_ ❑ Size: Diameter ; -- ------Depth----•---------------- --r------------------- ---- Liquid Capacity gals. : ,rC Privy:i Distance from n6arest-we.�ll-_-y_,�,,,�______--------------------------------Distance from nerest building-------------------- ❑ Distance to nearest lot line- =------ ------------------------------- ------------------------------------"-------------_•---'--�=----------- ----------------.---- I ��'� Remodeling and/�tepairihvg (describe):-_-__.-.---#------------------ ' -------------•-------------- --------- ------------------ ----• ---------------._..._-__-...-•-----..:.....-- ----_-------•___------•-- •_____-_----_--•-------•------•--- ......- -_ _ -------------------------------------------------------------------------------- -------------------------------------------- ------------- - •------- -------=--`--------------------------------------------:---------------------------- ! hereby certify that have .r par6'd thi application and that the worl2 will be done in accordance with San Joaquin County ordinances, State laws, and.rules.and regulations of the San Joaquin Local Lealth District. t rT1 (Signed) _.. ---- ._- __-Ow r and/or Contractor- ------------------=----- -- Title c=F By: ----- ------ ------•-- (Title)-- v (Plot plan, showing size.of'lot, location of system in relati fo wells, buildings, etc., can be placed on reverse side). �s , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------� I DATE '� VS =- = ----------- REVIEWED.BY!-------------------------------- ' ---------------=----------------------------------------------------------------------- DATE------------------------------- --------------------------- BUILDINGPERMIT ISSUED----------------------------- ----•-----------__--------------•--•-••---..-_---------------_ DATE---------------------•--•------ 1 Alterations and/or.recommendations:---------------------------------------------------------------------------------------------------------------------------....----•---------------------------- ---------------------------------------------------- k ...»..-_ .. ---------------------------••-----•--••--------------.---.---------•---..---...------------_-.._-._----.-----.----_--.....--_-_-------..--.----_--_--..-..-...__--__-_----._-.----.-_.•---.-.-...-_------------•--_....-.----- - F 5 FINAL -INSPECTION•BY:._—_------------------- � -k--- ----------- :Date--- --_--------•--4444-////-----•-.-r--�----J-- ----.r---�---- --------------: ------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California ES---9-2M ; Revised W-2100