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• d •e� `� Permit No. -...-........... --•----- ....... APPLICATION FOR SANITATION PERMIT . (Complete in Duplicate) 4 � 765' Date Issued/ . 7. ___ r,_ Applica4ion is hereby made to the San'Joaquin Local Health District fora e_r to construct and install the work herein described. This application is made in camplianc with County rdinance No. 549:. � ^~ JOB ADDRESS AD LOCATION ----- -- ---- = > ---=------ -•- - Owner's Na � �44 —Ol� - ---- ----------- Address•----•-- --- ---- --•---- ----- -- ...... .---- --•-------------- -------- � -----�------------------------------------------------------------------ Contractor's Name ------ --- --- - --------------------------------------------------------------------------------------------------------- Phone-------•----------------_------- ., Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer-Court ❑ Motel,❑ Oth r El , Number of living units: __1_:_ Number of bedrooms _ _ Number o baths __ Lot size __ _ __ ___ _________ _____________________ Water Supply: Public:.system ❑ Community system ❑ Private• Depth t - ater Table Character of soil to a depth of 3 feet:f Sand Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ f TYPE OF INSTALLATION AND SPECIFICATIONS: _ 1 (No septic tank or cesspool permittedif publ' i available within 200 feet.Septic ank: Distance from nearest wefl �___A�sewer c �frjc�m f nda ' I _ Mater al_:____ ��rr� ---- ------- --- No. of compartments----------/V_.t_._.-_-'Siz .----------�_� __---- iquid gepth------AV----------Capacity. : .!_ -- DFs os Field: Distance from nearest w IIO.` ance from foundation IP' Distance to nearest lot hint_ 4 p d ------ f __---Width of trench------- '' Number of lines_________ _ _ ___ . -_-_-_____ ength of each line________1______ Type of filter materi ` -__ ____ epth of filter material ___.__1_ __:-----Total length__________Js:5.9________________ Seepage Pit: y Distance to nearest.well_____________ ___Distance from foundation--------------------Distance to nearest lot line_______--__-_____ I ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------.-----------------Depth--------------------------------- Cesspool: Distance,from nearest well-----------------Distance from fojundation_____________i__-__,Lining material__.________.____._____________ 1 ❑ Size: Diameter--------k-----------------------------Dept h-,----- =' - t Liquid Capacity------------------ --=---gals. 1 Privy: Distance :from nearest well _________________________________________:...Distance from.'nearest building-------------------------------------__._. 0 _ ..Distance to-nearesttlot line---------------------- - --------------�, z_._-�.r- t--------------------------------------------- Remodeling and/or repairing {describe)---------------------------------------------------------------------------------- -------------- -•----•----------------------------------------------- k ........................................._--------------------_---------_--------------------------------------------------------------------------------_-------------------------------------------------------------------- - Y L ____________________________ ___________ ___--------------------------------------------------------------------------------------------------------------_---------------------------------------------_----------------------- I hereby certify that I have prepar"ed this application and that the work will-be done in accordance with San Joaquin�County ordinances, Stat aws, and rules and regulations•of the San Joaquin Local Health District.` (Signed)---- ---- -------- -------- --- -------- - ------ ---------------------(Owner and/or Contractor) -- - - - By:.--- i ----------------------------------- - (Title)- =------------------ ---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY , 1 APPLICATIONACCEPTED'BY ----------------------------------------------------------------------------------------------- DATE_:yo--•----..._:--------------------------------------- REVIEWEDBY----- ••-------------------- --------------------------------------------------------------------------------- DATE---�------------------•-----------------I -•---- BUILDINGPERMIT ISSUED----- ----------------------------------------- ----------------------------------------------------- DATE------ Alterations and/or recommendations:_- •---------------------------------------------•--..._..---------------------•------------••--- --------------------------------------------------------------- ------ ------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------- ---••-•--- -------------•-•--------------------------------s------------------------------------------------------- ---• ---- F __....__.- ________________ FINAL -INSPECTION BY:_ -----= ' l-------- Date._-------------------------------// --------------------------- SAN 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