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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) `"' ,7__( 7WE-F��,E7'>A17e_. Date Issued ._� � Application is hereby made to the San Joaquin Local Health Distr' � This application is made in com lien pct for w0ormit to consfru' !`sg—n �Z p I c�with Co nty-Ordinance No. 549. ct and install the work herein described. JOB ADDRESS A LOC r� �� O --- ----------- ---- wner`s Name---- -"--- - - -----"_""-- --- --------------- ._ -------- Phone Address Phone c = -� ----- - ---------- Contractor's Name___ ------------------------------------------ Installation . _ " "-""• __ --- ------------------------ a _ �" _ ,J Installafion will serve:a ResidenceApartment House --------- Phone----------------------------------- Commercial El Trailer Court ❑ Mot I Number of living units: umber of bedrooms _ t ❑ Other [� Water Supply: Public system [►/ t Number of baths -!-___" Lot size _ _ ']� Y Communit system -F 3....... Character of soil to a depth of 3 feet: Sandy y Gravel ❑Pr'SandyEl to Water Table .___ ft. Previous Application Made: Yes Clay Loam [� Clay ❑ Adobe Hardpan ❑ ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic +ank or cesspool permitted ifpublim se er is available within 200 feet i p 1 Septic ank: Distance from nearest wel) .__ . _,Disfan e afro found tion_ ' (��ater' I _ 1 � No. of compartments__.__. ' -- ------ ti a Liquid d pth. Dispos Field: Distance from nearest wel --- Capacity_. 1_t� �. "4- isetance from foundation_. Numkaer of linesP �fiance to nearest lot li Length of each line----------- -1 -- , Type of filter materi p p t1 Width of trench.___". - fh of filter material--- Total length �?_0 Seepage Pifi: Distance to nearest well-----------------------Distance from foundation___________" __ ❑ Number of pits---------------------- ---.Distance to nearest lot line_________________ e Lining material_ ------ Size: Diameter------------------- ---.Depth------ ------------------------- Cesspool: Distance from nearest well _____Distance from foundation-____._______ (� l ❑ Size: Diameter----------------- Lining material---------- m Depth --------------------Liquid Capacity----------------------------gals• ► Privy: Distance from nea�est well________________ ____""_ g i ❑ Distance to nearest lot line -------""----Distance from nearest building"---------------------------------------- Rem ------------------- ------ I ;. ---------------------- Remodeling and/or repairing (describe)------------------------------------ ------------------ ----•--.,.---•---- r 4-------- ------i.f -------------------------•--------------------•---------------------•--------------------•-•---------------------------------- ---------•----------------------- -------------- ---•---------------•----------•-------------------- - ---------------------------------------- - ----- - --- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ------------------------ I ----------------------.............-- ordinances, State laws, and rules and �egula#ions of the San Joaquin Local Health District. (Signed)------ r - ---------------------------------------------------------------------------------------------------------------------------------- 8y:..------•----•-------:--•-------•---•-------•----#----------•--- --- (Owner and/or Contractor) --•---------------------------•-------•------------------- - {Plot plan, showing size of lot, location f system in relation to wells, buildings, etc., canbeplaced on reverse side). I 1 FOR DEPARTMENT USE ONLY ! APPLICATION ACCEPTED BY__- -- r -------- --- -- ----------------- - ----------------- ---------------- REVIEWED BY---------------"-- DATE,-----' ---------- BUILDING --------------------------------------- -------------------------------------- BUILQING PERMIT ISSUED •- - DATE_""" __ ------------------------------- - -------- DATE---- - ---=-•---------------------------------------- i Alterations and/or recommendations:__--------------------- - ------•--------------•------------ --------------•--- _.. I ------------------------------ -- -----------"------------------------------- --•---------------•--------------- •------ ------------------ -------------------- --------,t ------------------- f _ FINAL INSPECTION BY:_- -;6�------------------------J Date_ --------- --------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street Stockton, CaliforniaLodi32 Sycamore Sfreet 814 North "C" Street , CaliforniaCeli{ornia E5-9-2M 10-52 Revised W-I100 Manteca, California Tracy, California