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APPLICATION FOR SANITATION PERMIT Permit No. ............ . ..r (Complete in Duplicate) Date Issued ______/Z1'.,� Applica+�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/witch County Ordinance No. 549. JOB ADDRESS AND LOCATION----!-�l_o _ -..__ ' '__.___M_ 4 Lj ----- ------• -------------------------------I----••---•--------------------------------•-- Owner's Name........... C_/—- 1p -------------------------- -------------------------------------------- Phone-----------------------•---•---•---- Address------- f r--y Contractor's Name----------- / R-1 S h!--..--_ -------------------------------------------•---•--------------------------- Phone----••----•----•---•---........... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. ___�__ Number of bedrooms —3--- Number of baths ._?— Lot size ./0_a_'___.aC----,1Ali.'--------------------- 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 ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes ❑ No Ea/New Construction: Yes Eg--No ❑ 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__;______________Distance from foundation--------------------Materia#_______._._.___-_____..______________---_._____- ❑ Xy No. of compartments--------------------------Size--------------------------------Liquid depth.----------- - - ---------Capacity----------------------- Disposal i I Distance from nearest well__J b`-__Distance from foundation--r --- �-.Distance to nearest lot Iine.,j/______ EO, - Ow'y dumber of lines------- ;;-^----------------Length of each line---1,.-.----sr...X>)_.Width of french-------?-V- ------------------ Type of filter material------1&__.f A.-Depth of filter material-------__.`'_____Total length--------------i;ld_---_____-______.__-- Seepage Pit: Distance fo 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_------____________.____.._____-_____. �y ❑ Size: Diameter------- ---- ------------- ------ ---Depth----------------------------- ------------------Liquid Capacity----------------------------gals. ry Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------_.-_______________._____. ❑ Distance to nearest lot line----------------------------------------------- -----__---------------------------.-_ ------------------------- Re deling and/or hix repairing repairina g�(describe describe :-------- e--- -C - . R — 1d J4r — f -/g ------- - / - -- ---------------------------- ------------------------- ----- - ---- --�--------{----- . ...... (---•0.1 ------ -Och ------------ -•-----• -----------•------------------------------ 1`a ------------------- --------------------------- ----------------------------------------------------------------------------------------------------- ------------------------------------------------------------ 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 regulations of the San Joaquin Local Health District. (Signed) �_S_f „�/yfC' ___O er and/or Contractor) ---------------- - ------------------{Title) r----------------------------------- (Plot plan, showing size of 0t, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- --- - - -- ----- --------- ----- - - ------------------------------------------------------ DATE--------•------------------------------------------ REVIEWEDBY----------------------- --- -. -- ...... -- -- ------- ----------------- -------------------------------------- DATE----..---------•------- BUILDING PERMIT ISSUED---------------------------------- ------------------------------------------------------------------ DATE_...��--••----•----------- ---------------------------- Alterationsand/or recommendafions:---------------------------------------------- -----------•-----------------------------------------------4------------------------•--------------------------- ---------------------------------------------------------------------------------------------------•---- ------------------------------------------------------------•---...•------------------------------------------------- -------------------------------------------------------------------••-------------------- --------------------------------------------------------------------•----- ----------------------------------------------------- --------------------------------------------------------------•--•----------------- ---------------------------••----------------------- ------•-------•--------------------------------------------- ------------- FINAL INSPECTION BY:_. ..- -- -- Date--- . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Es-9 t4E446 nrw000