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APPLICATION FOR SANITATION PERMIT Permit No, .__4_2Z (Complete in Duplicate) ) } Date Issued _��__ Applica4ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This pp p y Ordinance No. 549. JOB ADDRESS is LOCATION nc��Vt.--- --'-- "---- . ✓ �-'�✓, �-- . .-_ --------------------y----- ---- Owner's Name_- t1!A1,_`�;. rL_?? �,.` f2 �t1•� �7 � Phone ------------ -m --- ---------= --- -------- ---------•-•-------- Address----�.�-.'! 0.:, --------------- Contractor's ��- ' ca� ------------ � -----�--. .n----------- - -- ----------------------------- ---------- !y�, .1 `j= '� f = t Phone . _ _ T 0 Contractor's Name__r____._y____.__ __.,___-- __ �. r Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer -Court ❑l _Motel ❑ Other ❑ Number of living units: ____L Number of bedrooms _Z_ Number of baths ___ ._. Lot size 'f�11-" -t. —� ----------- Water Supply: Public system E] Community system ElPrivate (Depth to Water Table ____`9__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Ej Adobe Z/Hardpan ❑ Previous Application Made: Yes ❑ No [v' New Construction: Yes 211"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ccSeptic Tank: Distance from nearesf wel#_________________Distance from foundation--------------__Material------------------------------------------------- Cl No. of compartments_---------------r------Size--------------------------------Liquid depth--------------------------Capacity----- f Dispos Fie d: Distance from nearest well+-� O_-------Distance from foundation__O---------Distance to nearest lot�lin�C ______.. Number of lines__________ ____X4.__.-_______Length of each line_-_---_.--____,.___ _pt.____.Width of trench._____.___ +- �_._____________ Type of filter material ,AH Depth of filter material_______.------------------ Width length----------.f J __________________ 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 materia l__.----__.._____________.__________- ❑ Size: Diameter--------------------------------------De Depth--------------------------------- --- - ------Liquid Capacity----------------- -----•---gals. Ip '1 Privy: Distance from nearest well------------------------------------------------- from nearest building--------------------.________________._._. ❑ Distance to nearest lot line----------------------------------------------------------- ------------------------------------------------------------- ------------------- f p Remodelingand/or repairing (describe)=----------------------------------------------------------------------------------------------------------------------------------------_-------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ---------------I--------------------------------------------------------------------------------------------- --------------------------------------•------------------------------------------------------------•----------- 4 ---------------------•------- --------- ------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------- I hereby certify that I have prepared this application and +hat 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. {Signed} p '' f `"- 'y � ----------------------------------- ------------- (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 - -------------------------------- ----- -------------------------------------------------- DATES-- -- ---------- ----- ---•---------------------- REVIEWED BY ------ ------ ---- - DATE--��--------------------------------------------------- BUILDING PERMIT ISSUED------- ----------------------------------------------•------- ------ DATE-------Z,rN---------- Alterationsand/or recommendations------------------------------ ------•-----------------.------------••-------------------------------------------------..----•--------------•------------------- -------•-----------•-------------•------------------•------.--------------------------------------------------- ......---•--------•-------------------•-----------------------•------------------------------------•-------•- ---------------------------------•---------------------•-------- --------------------------------------------------------------------- ---------------------------------------------•----------------------•--------------- ----------•-------------------•-------------------------------- --- ---- ------- --------------------------------------------------------•--------------------------------------- ------------------------•-- 71- FINAL INSPECTION BY:------- -- --- '-- _._. Date......... ----- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; Revised W-2100