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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �s�sr 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 Count Ordinance No. 544. JOB ADDRESS AND LOCATIO��----� 4,;1 (� y ----------- Owner's Name- y - -------• X11-std✓ ------------------------------------ Phone------------------------------- Address------------ '- - --"-• -- ------- .r ------------•- --------------•----------•-------------------•----- --------------------------------------••-•---- Contractor's Name--- ------- ------------ -- ---------------------------------------------------0--------------------------------------------------I--- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motej ❑ Other ❑ F Number of living units: ___-- Number of bedrooms�3--- Number 'baths -_I---- Lot size --- .-Q__- -_- __ -------------------- Water Supply: Public system ❑ Community system El Private [Deptht ater Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam • Clay Loam E] Clay [:] Adobe C] Hardpan E]Previous Application Made: Yes E] No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pubic sewer is available within 200 feet,) Se tic ank: Distance from nearest well'` -__ 3 d p �}}��"Distan+�cQ fr�o�• foundation!____-_---__��Mf'evi�la --- ------- ------------ --PW No. of compartments---------- ,[_ _ .--'_Size,'17f*k�!__ --' -.___Liquid depth---�_4_'*' --_----_-_Capacity.... Dispos a Field: Distance from nearest well , ---_._._ istance from foundation_ -lf_d istance to nearest lop line:__�_.._____ [v]� Number of lines-__--_j_ _ Length of each line_____'__ � __-_ Width of trench---.-----_-- -?--------Type of filter materp g- �?..- : Depth of filter material----------�- ----Total length ____--•----..._-- Seepage Pit; Distance to nearest well---------------------.Distance from foundation....................Distance to nearest lot line----___--------_ ❑ Number of pits----------------------Lining material-----------------------Sizer.Diameter-----------------------Dept h-----.--------------------------- i Cesspool: Distance from nearest well-----------------Distance from foundation---"._;-------,_-..Lining material--- --------------------.------------. ❑ Size: Diameter--------------------------------------Depth----•------------------------ ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------`-------------------------Distance from nearest building---_------------_-____----_-.--._-------. ❑ Distance to nearest lot line-------------------- Remodeling and/or repairing (describe):-------------------------------------------------------------------------• -_--------------- ----- •---...--•--•-----------------------------------------------------------------------------------------------------------------------------------------------------------I----•---------••-------------------------------- 4. 14 -----------------------------------------------------------------------•-------------------------------------•-------•---------------- ------- I hereby certify fhat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. -ca. 4 _C' '' '---------------------------------------------•- -- --------------------------------(Owner and/or Contractor) (Signed)------------------------• By:-----------------•---•-•------------------------------------------------------------------- --------------------------------n-----(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can Wplaced on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ----- ------------------------- -- _ -- DAT REVIEWEDBY - - -------- ------------------------- -- DATE- ----------- ------------------- -------------- BUILDING PERMIT ISSUED------- ------------------------------------------------------- -- - --- - ! DATE----lgk%------- Alterations and/or recommendations:-------------------------------------------------------------------------------------`----------•-----• ] 5 -.----_---•__...------------------------------------------------------------•-.--------.-_-----------------_--__-------------------------•_---...--..._•--._---__--------"_---__.-----_-----_-•_-----._....---------------- ----------'---------------------------------------------------------------------------------`----------------------------------------•----------------•----------------------•-----------------------------------------------: -------------------------------------------------------------------------------•-.------------------------------------------------------------------------•------------------------------------------------------------------ INSPECTIONl/ / FINAL INSPECTION BY: ----------------------------•-•--. Date.--l./ -C� _ s---------------/----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Streef Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M ; - Revised W-2100