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APPLICATION FOR SANITATION PERMIT Permit No. ....................... (Complete in Duplicate) l f ` :,- , .. . x _ ..v __.. _ s Date Issued Applica+ion is hereby made toy 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 Ordinapce No. 549. x - JOB ADDRESS NQ CATI�iiJ___4_'----- -_ --- f fps �L ___ _____-.-. Y _ _ -------------------------------- _ _ _ _i _ r _... ._. _-_---_--.___._•______________________________ ____________ _.____________ Ownetr's Name � - - ------------- ----- ----- -- Phone--------_--•--------------..- Address----------------------- = � ------- Contractor's l ------ ------------ -------•--=-••---- •------- ------•----•----••------- ---•-----------------•- x Contractor s Name-----_ = I_I F F---- .- ------- .__ Phone.-------•---- ---•'3-------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ M tel ❑ O+der � Number of living units: !______ umber of bedrooms -------- Number of baths ___`_..`Lof size _ 1 ©___.________---_--_--______ r t Water Supply: PublicsystemCommunity system.0 Private E] Depth to Water Table ------- ft. " Character of soil to a depth of 3 fee+: Sand Gravel E], Sandy Loam 0 Clay Loam E] Clay El Adobe `[,Hardpan ❑ 1 Previous Application Made: Yes E] No New Construction:'Yes, No .❑ € TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted 'f ublic sewer is available within 200 feet.) ` 'a - Sept'sc Tank: Distance from nearest welL___ . Distcfe fr m f .relation______ __ _______.Materiel No. of cons artments:___._. ._ �__.- {Size . _% _ Liquid e th__ .____-_ Ca acit;u ---0 Disposal Field: Distance from nearest well-- Distance,fyom,foundation/�`�istance to nearest lo+ line_r__Tf; ____ W Number of lines___________ _____ .-_______.._:Len th of each line_____________ ] Width of trench__________ _ "1 9 -IT Type of-filter materi J�`�t�" ,---,__Depth of filter material--_----_/_ 1-_______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.,well__..__________________________________________Distance from(nearest building------------------------------------------ ❑. m .- .., - , " - •.��, _.. -- --------------------------- Distance fo nea kest'lot Sine_---."-.�_"� Reodeli an ..dor repairin '(de gibe :. -----------------I--------------------- ------• ---------------------------------------------------------7-------------•------------------------ --------------------------- ---- ------------- -�...... -------------------------------------- -------- 4 l+� _________________R_.- ________________________-------------------------------------------------------------_____________________________________________________________________________________________________________________ .1 hereby certify-that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, fate laws., and rules and regulations of the San Joaquin Local Health District. _ " f !/h -------------------------------------1-1------- -. .Owner and/or Contractor (Signed)•- -- - -----•--- ---------------- { / By: r,r ii--------- (Title (Plot plan,.showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). l; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ ______ DATE__,__-________-_ REVIEWEDBY---------------------------------- ----x- t------------------------------------- DATE_-:--- -------------•----------------------------------- BUILDING PERMIT ISSUED------------- I------------------------------------ DATE------- '' - ......... Alterations and/or regommendations:____: - ------ - -�--'----'--•-------------- -- ... '-----t---�-----------------'----y--'-'----- -- -I.. -----= •-•------•--- - ----------- AA_ - - ------=------------ --- -- -------"o--------- _;ZAPA� FINAL INSPECTION BY: f.Mi."f R.]fA? ��1J¢/y Date- :-._I ..---J --- �^ ►�'� ` t. 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 Cfi