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APPLICATION FOR SANITATION PERMIT Permit No. .... (Complete in Duplicate) l�j� �� 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 y4fh County Ordinance No. 549. JOB ADDRESS'AND"LOCAT ON.. _"""" ------ __P- --A-au. � P �a.r ""Z, . b 1 ��}} Owner's Name_ vR- -_C�3 -- -- " ---------------- Phone ------------------------------------ Address___ _.0,..:. .. ' l: Contractor's Name •---------•----- • ------------ Phone-------- ---•-- ---- -------------- ---------- Installation will serve: Reside ce ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other . i Number of living units: -------- Number of bedrooms _---Number of baths-t'-_'—Lot size --------��-_(�t,4or . _"""•_""""-_ Water Supply: Public system E] Community system [:] Private Depth to Water Table � ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [-] Sandy Loam E] Clay Loam Clay ❑ Adobe E] Hardpan E]Previous Application Made: Yes E] No Sand New Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: � '(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-l------------------------Capacity--- ------------------ Disposal F Id: Distance from nearest well 14 44.--.Distance from foundation--- """" Distance to nearest lot I' a-- Number Q of lines---- --------------------- --Length of each line--8-Q:f'---------------Width of trench---- ---------------•--- Type of filter material-6 'C _Depfih sof filter material_._._ "Q__."."-_Total ------------ --------- 0-__"""_ Seepage Pit: Distance to nearest well_------____.----_"___Distance from foundation--- to nearest lot line-_________-_-.__ o ; � � 3 ❑ humbe`r of pits. Lining material Size: Diameter-------------- --------Depfin Cesspool: Distance from nearest well_______"_________Distance from foundation._,................Lining material______________________________- ❑f ". = Size:rDiameter� ------------ ----------Depth----------------------_-------------------- = ;---Liquid Capacit als.- Privy: , Distance from nearest well--------------__;_--_ _- ____Distance from nearest building - y w 4 ---------------------- { Distance to nearest lot line________-_____.__,________________ _ _ -------------- Remodeling and/or repairing (describe:-___--.__---------------------- ------------------------------------------------ a � ------------------ ----------------------------------------- ---"----------------•------•-----------•------------------------"------••-------"-------- I hereby certify that I have prep ed this application and that the work will be done in accordance with'San Joaquin County ordinanus State laws,"a�d� ules an reg lations of the San Joaquin Local Health District. t , F (Signed)_.._r___ ------- ._ /________ . r -----(Owner and/or Contractor) �y:----- - -- ---- �s+r - - ------ (Ti[Title)------------- ------------ _ --� .Y. -v ------- ot plan, sowing size of lot, location of system in c ation to wells, buildings, etc., can be placed on reverse vers side). Y 1} ` FOR DEPARTMENT USE ONLY T APPLICATION ACCEPTED BY--------- DATE---- REVIEWED = f BY f DATE = -- r--� ------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------ -----------. -- DATE-------------- Alterations and/or recommendations:___.___._____.__.._-_ - ' -- -------•--- ------------------------ ---------------- -------- i --------------------------------------------------------- ______________________________-____..i--.______-----__"- -_______. ..__ - �i�FINAL 'INSPECTION BY------------ - Date.........-------- /�'` C - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100