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` APPLICATION FOR SANITATION PERMIT Permit No. ...... �.............. (Complete in Duplicate) u II -sem Date Issued -------- ------------ Applical-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 County Ordinance No. 549. �� JOB ADDRESS AND LOCATION ?- ........ ,�jj Owner's Name.--------------------Ail Phone7f/J �lp ---------- Address. �J% Contractor's Name------ -_-- -: t[�o--�lC-.--_--- ----------------------------------------------------------- Phone. Installation will serve: Residence gj'�Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1_____ Number of bedrooms 3--- Number of baths Z----- Lot size . a'r:_'' .10— z _T_ '______________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla oam ❑ Clay ❑ Adobe E5--Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYKE OF INSTALLATION AND SPECIFICATIONS: ll (No septic tank or cesspool permitted if pu iic sewer is available within 200 feet.) .� S;o' Septic Tank: Distance from nearest well________:________Distance from foundation__4 _ ._.__.Material -----------------------__-___-----`_-- No. of compartments------ ------------- ---Size__-�_3 Fi._ _.-____.-.__--Liquid depth---_�"_�"__�-----_-____--Capacity-,�� ,.� Disposal Fi Id: Distance from nearest weN Hg - Distance from i'oundation__ _Q_ ___Distance to nearest lot line_____.`_ _ ` Length of each line__ ` -i-30......Width of tren h_.-�-`��'----------------- Number of lines-------�---- --- g _ Type or filter mater+aL__ -- -------Depth of filter material__! - -----------Total length__._.- --,__ ............._�II Seepage t: Distance to neares/tt well _'_._ _t_-�r Diistanc ff fqundation-A2---......Distaan Distance to nearest lot line-------- 7 UR Number of pits---/-----_--....--Lining material-------------_�-9.....Size. Diameter---_c�a7..,�1.__...__-Depth-----1 J. ---__ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--.--.--.-__-----.-:--_--_---.__-___ ❑ Size: Diameter------------------ -------------------Depth------------- - --- - ---------- .-----_---Liquid Capacity-----------••--------------gals. y Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------------_---_-_. ❑ Distance to nearest lot line-------------------- � y Remodeling and/or repairing {describe)---- --------------------------------- -------------------------•-------._......---------------------•-••---------------•---•--------------------------•• 'U ---------------------------------•-----•-----------------------------------•-•----------------------------------------------•-•-----------•-----------------------•-•---------------------------•--•------------------- "V I hereby cerci that I have pre ared this application and that the work will be done in accordance with San Joaquin County ordinances, State I d rules.an regulati a San Joa n Local Health District. F aJ t (Signed)------------------ ---- { -f S- 1 -------------------- -- ----- ----------- ............ ---- ------- Contractor) By:---------------------------- - -•-------------------- -----(Title)-- - ti` ay ------------------------- (Plot plan, showing size of lot, location of system in relatio t wells, buildings, et , can be p ced on reverse side). FORD ARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- -- --------------------------------------•--------------------- DATE----- -------•-----------•---------•--- -----------•---- REVIEWEDBY-------------------------------------------- ---- --- --- --------------------------------------------------------------- DATE..-- -----�--- ------- BUILDING PERMIT ISSUED.---....:.-------------------- ---- -- -`--•--------------------------------------•------- --- DATE----------- ----- Alterations and/or recommendations_____________________ __ _ -- -- ----------- --- -------------------•-•-----------••------------------- --------------------------------------------------•------•---------•--------:---------- -----------•------- -- ------------------------------------ ----- - -------------•---••-----------• ----------------------•-----------------------•------------------••-- c��C1S FINAL INSPECTION BY:---- ------------ ----------------------------- Date----- .------------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore $free+ 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M Revised W-2100