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APPLICATION FOR SANITATION PERMIT Permit No`?-_. `3l__ x ' ' '-�''� (Complete in Duplicate} Mf Date Issued ----------------------- 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 with County -rdinance No. 549. , JOB ADDRESS AND ly0CATION----- --- -�-(J- - ------ -- ----------------•----•- - -•- ` Owner's.Name---------ee-�C - - -r o--+---------` ,. ----.f�------------------- ------ Phone------------------------------------ Address------------ -_Ca"- ----------------• ---------•--- - -----------------------------------•--------------....._..._......--•------------------ --------•----------------------•--•------- Contractor's "Name----- ------------------- ------•-------------• --------------------------------------------------------..-------------------------------- Phone----------------------------------- Installation will serve: Residence1 Apartment House ❑ Commercial E] Trailer Court [3 Motel ❑ Other E]Number of living units: __�[-_._ Number of bedrooms _ _. Number of baths --1---- Lot size oS__ �-5---"------ _________________ Water Supply: Public system Community system ❑ Private ❑' Depth to Water Table _______ ff. Y Character of soil to a depth of 3 feet: Sand E❑ Gravel ❑ Sandy Lo;"No m Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No-W New Construction: Yes ❑ Y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet") f� Septic ank: Distance from nearest wel(Disfar� fro ffou tion____Q_____________Mater al_______.______-___..____..___ < �j No. of compartments nts_------- "_"_»__Size___x'?-" _____•___Li idrdepth_�.�_____. ____.__."Capaci-y__Ll"-D__ Dispos 'I Field: Distance from nee,rest w IC��!-� Distance from foundat' F_Distance to nearest/looct I- e d Number of lines-_"------- - ------ -- ---------- -Length of each line--- -- -- -_- rj_---Width of trench----________--___-_-f__.______-- Type of filter mater _ ,__ ___ ____ pth of filter material-------- __ _ Total length-----------�e -- 4 Seepage Pit: Distance to'nearest well_____'_---------_-----Distance from foundation--------------------Distance +o nearest lot line----------------- F-1 Number of pits----------------------Lining material-------------------.---Size: Diameter-----------------------Depth----------------------.._::------- r ' Cesspool: Distance from nearest well-------------.___Distance from foundation------------------- Lining material__._.______._____.______..__-_-._._._. ❑ Size: diameter------- -------------- ----- De th -----------------------------Liquid Capacity---------------------------gals..i "C R, Privy: Distance from nearest well ________________-------------------------:___._Distance from nearest building------------------------.------.---______- O ❑ Distance to nearest lot line-------------------=---------------------------- ---------------------- ------------------------------------------- ------------------------- Remodeling and/or repairing (describle):_.___________________ _ ----------------------------------------------•--------------•--=--------"•---------------------------------•-•---.......-•--------------------------------•---------------------------------•------------- ------------------ 1 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 andiregulations of the San Joaquin Local Health District. (Sined �I �.. ----------------------------------(Owner and/or Contractor) 9 )----•--------- $Y: ----------------------=-------------------------------------------------•------------{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 t APPLICATION ACCEPTED BY ---- - - -------- -------------- ---------------- -- ---------------------------------------- DATE------------------------ -------------------------- REVIEWEDBY------------- ------------------ __- __ -------- ------------------------------- ------------------------------------- DATE ---------•-••------------------------------------ BUILDING PERMIT ISSUED---------------------------------------------------=-----------------------------------.-"-_-_"--_"_- DATE-----� ---------------------------------- _. --------------- Alterations and/or recommendations:_:_, � --- -----------------��------------...._..----•--••-----------------.- / s�_ .l FINAL INSPECTION BY:-- Date.---//-``/�-_�S._—..�-------------- ---------------------- 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 F�q -5-6 ATw00. n