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APPLICATION FOR SANITATION PERMIT Permit No. ___-_1....1___ � (Complete in Duplicate) L —7=T----7`,T---7-.,,,-__ Date Issued Applica�ion'is hereby'.made to the San Joaquin Local Health District-for a permit_fo construct and install the work herein described. Th+s application is made incompliance with County Ordinance No. 549. JOB.ADDRESS A_ND LOGATI6N----__----------- '__- -UJ �a ----------- ---•-•-------------=-= ------------------- ------------------------ Owner's'Name---=----"�m. _ .- - ' °' __ ------------- -------- --------- - =-'------------------------------------ Phone--=--------------------•---•---•---- Address_____________ ._.._54,rr,,�-_--------------------------------------------------------------------------------------------------------------------° i Contractor's Name r ... ==-=--•--•----'-- --------------------------- ----------------- Phone------ --------------._...--_----_. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ------ Number of bedrooms _ ---- Number-of baths .------- Lot size -_4 X_104----------------------------------- Water Supply 'Public`systein.V Community system'❑ "Private'❑ •:Depth to'Water'Table ':______ ft. 8 Character of soil to a�depth of 3.feet:. Sand ❑' Gravel ❑ Sandy :Loam ❑ Clay Loam ❑ Clay ❑ Adobe` [ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation------------- Material__.-_-.-..-_---._-.---.---_._------__------_--,. ❑ No. of compartments.- ---,-Size--------------------------------Liquid depth----------------- --------Capacity----------------=------ I Disposal Field: . Distance from nearest well--------------- Distance from foundation-----------------.:-Distance to nearest lot line----------------- ; F1 Number of lines----�-------------------------- Length of each line-----------------------=-----.Width of.trench----------------------------------- Type`or' filter material_______________________°Depth of filter rnateriai___..___,___. ..__..Total length---------.---__.-..._. Seep ge Pit: � Qisfiance to nearest well- _ _-�-___�_ ----'-Distance from foundation_________.............Distance to nearest lot line----------------- Cess'ool: � Distance from nearest welh------__pistance from {' :____.'__.._.__.___Depth_________________________________ ❑ ' Number of pits------?----------------Lining material-------------- ,Size: Diameter_.+ p oundation--.1p_.:_--:-..Lining material.___ --------- d ' z .De th = Liquid Capacity Sip: Diameter. -------- --. - -------------- =---- g - Privy: Distance from rearl- rest wel _-_:_-------- ----------------------------i_-__Distance frorninearesf building_._______..___...___.____.______.____-- + []„ m. Distance'to nearesti-lot•line------------------------------------ ------------ --- .-------- „ Remodeling and/or repairing (describe) - ---------------------------------------------------•-----•---=------•-------•------•----------------•---------•-------••---•---- i r -------------------------------------------------------------------------------------------------------------.........._.....--..---._- .___---------- ----.--__----.-.----._--____..-._--_-_-_-------_----___-____----.-._ t. i : . ------------------ ----- ---------------------------------------•-••--------------------------- ----- ------------------------ • -------------------•---------------------•------------------- - ---------- I hereby certify That I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stated wa s;and rules and regulations of the San Joaquin Local Health District. (Signed)---- €`_ ------- ---------------------------------------------- ------------- -----(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). f i FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY. - DATE ----------- 1 r - F DATE REVIEWED SY-------.----�------------------- ---- �- BUILDING PERMIT ISSUED------ a ----------- ---- ------------- ----------------------- DATE.._.!___ - -��-t---�------------------------------ ------ - ---- Alterations and/or recommendations:,_$....::.-------.... r -------------------------------- -------------------------------•------------------------------------------------------------------------ ---------------------------------------------------I...........I•---------------•----•--------------------------- -------•---------------------------------------- ---------- ---- ----------------------------=-------------------------------------------•------------------------•---- ---------------------------------------•--------- ------------------------- ---------- -I------- -------- --------------------------------- ---------------•----•------------------- --------------- ------------+ - ------------------ = -------------------------------------------- ---- -----•----------------------•----------------------- I Jw r FINAL INSPECTION"BY: -----------------�-- ----------- Date_ `-------- `. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 745446 A7W09D 12-54 +