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APPLICATION FOR SANITATION PERMIT Permit No. ____- (Complete in Duplicate) Date IssuedcZ • Applira*ion is hereby made to the San"Joaquin Lo al-HealthtDistrict for a permit to construct and install the work here i�describe This application is made in compliance with County Ordinance;hfa. 549. ,�Z' ' 1 ' �5 JOB ADDRESS AND OCATI N -�--- - --a -------------------------------- = Owner's Name........ --•---•- ,�✓ rG_ •- � - Phone---3-gam/ 7 -- = = ---------------�------ --•--• ' --}��, Address__.. °Z ? '1� ----------------------•-----------------•-----------.:.. . �T/1 ' Phone.l`7Tv qra �i � Contractor's Name-------- _ 1. Installation will serve: -Residence a Apartment House 171 Commercial ❑ Trailer Court ❑ Motel E] Other ❑ 1 Number of living units: �_:__ Number of bedrooms ______._ Number.of baths ___;___- Lot size g ---•---------------- ------ - b� i f ii 1 Watet Supply: Public system �am munity system ❑ Private`❑ Depth to Wa#er Table yft. Character of soil to a depth of 3 feet: Sand ❑ G'ravel,Ej' Sandy Loam ❑ CI y Lo m ❑ Clay ❑ Adobe [.yiqardpan ❑ . Previous Application Made: Yes E] 'No.[!�-'NewConstruction: Yes [Yro ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: _(No septic tank or cesspool permitted if public sewer is available within 200 fee+.) ., Septic Tank: Distance from nearest well�fQ�_ Distance from faundation_.1Q_ _____Mate/ial_� C__ ____ _____________________. No0 of compartrrients'}__._..°2-------------Size__�G_H_�! D-r�_Liquid depth---_'�__-lid-----------Capacity----4?40------ Qis osal Field: Distance from nearest well-fb _.____._Distance from foundation -�______Distance to nearest lot line____`'__________ p�� Number of lines--------- --------- ------- ----Length of each line----a_4.- ----- Width of trench.--_2y. I.. S { Type of filter material_____._�?o :__Depth-of�filter mater.ial_,___ _____Total length______ -�___________________________ ' y. -r__-__.Distance to nearest lot line____._.-____- Seepage Pit: Distance to near well from foundation__ . Number of pits----- -------------Lining material_-r _.Size: Diameter-.- -�r-------.Depth---_ter__---------•------:-- Cesspool: Distance from nearest well--------------___Distance from foundation_____.______..__.-- Lining material------------------------------------ Size: Diameter--- -------------------------------Depth----------------------------------------- - ------._Liquid Capacity- ----------.---------------gals. ❑ I --Distance from nearest building t Distance from nearest well------------------------------- ------------------------------------------- Privy: I pistance to nearest lot line-- -------------- ------•------- - ------------------ -------------------- ----------------- ---- Remodeling and/or repairing (describe);--------------------- --- --------------------..--------------------------------------------------------- -------------------------------------------- 1r _ ° �9_)--------------------------------------------------------------------------------------•------- ---------------------------------------------i -- --------- -------------•------•----------------------------------------- I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. 1 ( / } (Signed "� Ow er and or Contractor ��J_.------- ---- --- (Title) - Y (Plot plan, showing size of lot, location of syst in relation to wells, buildings, etc., can be paced on reverse side}. FOR DEPARTMENT USE ONLY i APPLICATION ACCEPTED BY------- ------------------------------- -------- 5 ---------------------------------- DATE -------------- --------- ---- -- REVIEWEDBY-------------------------------------------------------------------------------------------------------------- RATE - ...._.. ---•---------.-------- BUILDING PERMIT ISSUED -- --------- ---- DATE - Alterations and/or recommendations:---------- ------- --------------------------- -------•-•-------------- -------------------•------------- ---------------------------------------------------------------------------------------------------- ---------------- ---------------------------•-----------•-------------•-•--------•----------------------- - ------- ------------------------------------- •-•- I u . . FINAL INSPECTION BY------------- ------------ ----------- ---- - Date---------------/ ---7--- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street i 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 {