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APPLICATION FOR SANITATION PERMIT Permit No. ..... - -3-� ' (Complete in Duplicate) `S pDate Issued -5--� _----- Application 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. / 119 _, ---------- � r, �9------------------------------- JOB ADDRESS AND LOCATION----_. _f��___- -=- J` fin------- �J � Owner's Name---- _,� Y�n�S �-/ __len_,_ ,Q - �9,]---,64PO -"r--- r - -- Phone-�,��- l a ----------------------------------------------- Address.. ------------------------- �^=f__ Contractor's Name---- _s.1^Y--:. -_.. � f --------------------------------------------------- Phone--'7 ,e !_-------- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I--_ Number of bedrooms - __ Number of baths ---L-- Lot size --- ------------------------------ Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand 4 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ 1 `4Lw Previous Application Made: Yes 9- No ❑ New Construction: Yes E] No ❑��,.. ..,,.ra a•�7 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- -0---_Distance from foundation--- --- No. of cosapartments-----rY---____---_--Size �� _ �'� ��--Liquid depth_-J4Ar_`- -------- Capacity csal Field: Distance from nearest well--Distance from foundation---- "_-Distance to nearest lot line"" ;.P aj I Number of lines-----------------------------------Length of each line-----------------------------Width of trench------------_---------------------- Type of filter material-------------------------Depth of filter material-------------------- -Total length.---------------------------..------------ 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 material---------------------------------__ ❑ Size: Diameter--------------------------------------Depth--------------------- -----------------------------Liquid Capacity----------------------------gals. �. Privy: Distance from nearest wefl-------------------------------------------------Distance from nearest building--------------------..------_----_-_-----. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing {describe)------------------------------------------•-••------------•----------•----------------------------------- -----------------------•---------------------- ordinances, State law an sand regulations- a --------------------------------------anhawwill --- e in - co Sa ----ui -------------------------------------------------------------- - -•--- i hereby certify that I have prepared this app;cation and that the work will be done in accordance with San Joaquin County f the San o quin Local Health District. Si ned Fr '°� ( Contractor) ( �9 ) -- - -� �r - �A...�.. ----- ------------------------------------------------------------------(Title) .� t_---------------------- [Plot plan, showi g size of lot, location of stem in relation to wells, buildings, etc., can be p aced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------- ---- ------------------------------------ DATE.SP , ------------ --------------------------- REVIEWED BY--------------------------- -------- - --------------------------------------- - ----------------------------------------.. DATE------ BUILDINGPERMIT ISSUED--------------_-------------------------------------------------------------------------------------- DATE-------- -------------------- ----- ---------- Alterationsand/or recommendations-------- -------------------------------- -- -----------------------------------------------------------I---------e------------------------------------------- ----------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- ------------ --------------------------------------------------------------------•----------------------------- ----------------------------------- ------------------------------------------------------------------•------ FINAL INSPECTION BY Dat y - -------------------------------- M_ 77 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-4-2M 8-51 Revised W-2100