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Permit No. __. .. ........ APPLICATION FOR SANITATION PERMIT .. " -- r (Complete in Duplicate) j S p ) Date Issued ".-" ---f�•-1 1 � the work herein described. �y pplica{ion is hereby made to the San Joaquin Local Health District for a permit to construct a 1� his application is made in compliance with County Or&nance�^No. 549. �j�� ` ' ,Y-!_v_n 44 `" --------------------------- --------------------------------- JOB ADDRESS AND LOCATION"_� --- Phone----------------------------------- tr--------- � 1� - - ------------ ----------------------- ---------- K Owners Name ------------------- ------•-------------------- I --------- - -----1 '`f '''' -- ----------- ` Contractor`s Name"------------------------------------------------------- Motel ❑ Other ❑ Installation will serve: Residence] Apartment House ❑ Commercial ❑ Trailer Court Number of living units: __._____ Number of bedrooms _ Number of baths .___;.__ Lot size __- .____ � -! �f ` ter t. Water Supply: Public system 1-1 Community system ❑ Private Depth tClayaLoam aQe Clayf❑ Adobe6r Hardpan El Charat_ter of soil to a depth of 3 feet: Sand F1Gravel F1 Sand Loam ❑ Application Made: Yes ❑ No� New Construction- Ye No [-IPrevious App hi 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___5-0------- Distance from foundation_._. 'V" Materialy v_61 _i Sit'- <_3 ---Li uid depth------- G Capacity.. No. of compar+mems---------- --- ----Size--------- ----- q r !nearesf well_..-" 4.�-f Distance from foundation__.--_. to nearest lot line.- ------• t�'' EN �'�a- _' Width of trench ------ ru W Length of each line.-"" . ---- Dis osal Field: Distance fro r __ � Number of lines_ g otal len th_-------- -------------- �/ Type•of filter material._.- #_��""---Depth of filter matenal"----�� Distance go nearest lot line________________ Seepage Pit: Distance to nearest well---------------------- from foundation___________ _" . Number of pits. Lining material-----------------------Size: Diameter-----------------------Depth--.----_------ -------- ❑ Cesspool: Distance from nearest well_.___--""-------Distance from foundation...._.--."---------.Lining material____._------------------------als. _ ❑ Size: Diameter"---------------------------- - Depth--------------------------------------------------- ----------------- - --- --- --------------Liquid Capacity-----------------------------9 Distance from nearest building-------------------------------'- -------': Privy: Distance from nearest well" ---------------- ----------------------------- --------------------•-------------- ❑ Distance to nearest lotine__""------"-------------- --------- Remodeling and/or repairing (de'scribe _ _ - :____. ._.._- __.,----------------- _____________ --------------------------------•-----------•-----------------•--- t ----------------------------- :� =------- ----------------- =---•-------------------- --------------- ---------------------------------------------------------- ------ ------- co--------------------------------------with a -- one I.hereby certifythat l have'prared thire s application the San Joaquin e orkHeall e d District. accordance with San Joaquin County ordinances, ate law4ales�. and ------------------------(Owner and/or Contractor) (signed) (Title) -- ---------------- -------- - --=-------------------- (T� BY- . ----- g (Plot plan, owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE---------- G� y�]� �, --------------------------------------------------- DAT --�- ----------------•-- ------•--------•-----------"------ -'I ---- --------- ----- -- REVIEWED BY------------------------------------ ---------------------- - ---" ------------------- ------- DATE--------------------------•---- ------------- -------------- - -- - --- BUILDING PERMIT ISSUED-------•---- --------------------------------------------------------------------- --=--- -------- -- - - --------------•---------------------------------•---------•----------••----------------•----------- -- ------ ----- - - Alterations and/or recommendations------------------ ---------- --•------•---•------------------------- -------•---------- -------- ---------------------------------------------"--- ------------------------• --------------------------------------- Date---- ---- -------- --------•-------------------- FINAL INSPECTION BY: -1�= --/ -------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street $14 North "C" Street 130 South American Street 300 West Oak Street Tracy, California Stockton, California Lodi, California Manteca, California FS-4-2M Revised W-2100