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j r APPLICATION FOR SANITATION PERMIT Permit No��.-0••4-•---•- ` (Complete in Duplicate) � bate Issued_Y�J-�-- '_ Applica�ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the worms herein described. This application is made in compliance with County Ordinance No. 544. - ----------------------------------------- 3 JOB ADDRESS AND OCATION--___ --__._ f ------- --------=---=�---------- -�- Phone-- - -. --••----- •--- , Owners Nam 'i....-- r ------ •---- ---•-------•--- ------ Addres _ - // ---- Phonal ` Contractor's Name---------------- - f------ Motel .Other ❑ Commercial' Trailer Court ❑ ❑ Installation will serve: Residence Apartment ouse ❑ r ❑ Number of living units: '� Number of bedrooms- -. Number of baths _-2 Lot size -- Water Supply:R �Publicss stem Community system ❑ Private ❑ Depth to Water Tableft. Y Character of soil to a depth of 3 fee#: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Ye No ❑ F INSTALLATION AND TYPE O SPECT (CATIONS:, (No septic tank or cesspool permitted ifp ublic sewer is available within 200 feet.) r Materi l__ --- --------- Stance from foundation____- ep--- Septic Tank: :' Distance from nearest well_ ��/ �t/ •Li uid de th-��- ---3-------Capacity �0 No. of compartmen.}s-"-:.-_,---- -----Size-- ` - Dis I Field: Distance from nearest weltfJ ---Distance from foundation.____.',- - .---.Distance to nearest lot•li�e_':-- ._-...- = =Len Length of each line--------• ----------• Width of trench'_-------`�� t_____----=---------- Number" of lines___"__,�__-----•----- -- g e� VAI ` Type or filter material _ _ ----- - Depth of filter material_--- -- -- To#al length.------.-�r----- ; --- --~� "' Distance fr •fo dation_______U--_.......Distance o nearest lot Seepage Pit: Distance to nearest well- ��-Size: Diameter----- Depth 30 Number of pits----- - - ----------Lining material- _ : aCesspool: Distance from nearest well_______________Distance.from foundation--------------------Lining material___, ___-_______._._________. Size: Diameter..- „__--- :Depth i - Liquid Capacity = gals. ❑ t =-Distance from nearest building-+----'------------------•----' Privy: Distance from nearest well----------------a--- _ -- -- ti Distarice to'nearest lot line______-'__:_____.___-------------- -- ----------•----•--- ---- �,,. - --------------- _ .--------•------------------------- i ------- fi --- ------------------------- -------------- -------------- z s �:1 S I hereby certify that I have prepared this application and that the work,will be done in accordance with San Joaquin County ordinances, State laws, and rules and regul tions of the-San-,Joaquin Local Health District. s ------------------- --(Owner r an /or Contractor (o ----------- (Signed) e 4 �. -----------------------•------ T�tl ( e 'r -•--•.-- -- --r--------------- BY-•------------------ -- (Plot plan, showing size lot, location of.system in relation to wells, buildings, etc., can be ed on reverse si i. i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ---------- I ------------------------ DATE------------------ �- " --f '� ---------•- DATE--------------------•------------------------=--:---------- REVIEWED BY---------------------------- - -----------------<--------- -------------- -- -- BUILDINGPERMIT ISSUED----------------------------------------•--------'--------------=--------------•---- --------------- DATE Alterations and/or recommendations•------------------------ ------- ---- - - -- I ---= -------------- ----- -------------------- ------------------------- I , Date -- ---FINAL •INSPECTION BY:----- - ---- SAN f t JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California Y� cc o_9M : Revised W-2100