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rl APPLICATION FOR SANITATION PERMIT ✓ Permit No.�. '' / F (Complete in Duplicate) Date Issued --�-----_-,5--- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herei described. 1 This application is made in compliance with County Ordinance No. 549. I JOB ADDRESS AND LOCATION__.. _ /Owners Name------------------------------- - '� AdcEress-----------------------' _ _ -------------- Pone---•------------------ - ------- ---- `� Contractor's Name Q -- --------- •-- --- - Phone---- -- - Installation will serve: t Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel' Other ❑ Number of living units: _-�-- Number of bedrooms l-___ Number of the -/- �__ - Lot size ----- ----- - ------��-------------------- Water Supply: Public system ❑ Community sys#m❑ Private Depth to Water Table ft. Character of soil to a idepth of 3 feet: Sand Gravel Sand Loam ' y ❑fclay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Sand Construction: Yes ;PNNo ❑ x TYPE OF INSTALLATION AND SPECIFICATIONS: _ (No septic tank or cesspool permitted if public sewer-is available yr ithin 200 feet.) f Septic Tank:- Distance from nearest weEl___'__....s-•._____Distance from foundation__._._____. Material_____-.`.No. of corn partments_ ________ --SizRe--------------------------- Li Liquid depth--------------------------Capacity----------------------- [[[��►��, DisDistance from neares wef :_Distance from founda#ion__ ___ -- _;__.Qistance to nearest tine Number of fines______ ___ _____ _- Len` th of each line_______ ___ g ��_ - - Width of,#Tench--- - ----._l ------------ •--- C Type of filter material _�_•Depth of filter material__ .( !.-' -_..Total length__-_------ _�___- ..,��, ._ i!Y ------------------ �. Seepage Pit: Distance to nearest well------_------____-----Distance from foundation----------------------Distance to nearest lot line________________ p g"material-----------------------Size: Diameer--------- -- t ❑ Number of its. t Linin Depth - Cesspool: Distance from nearest well------------------ ____-_-___'_ Distance from foundation_____ ______ _____ Lining material____-_____-_-___:_..---------------- Diameter ❑ _ Si ---- ----------' -.Depth - Liquid Capacity - R p - .,.:..__ti -------gals. Privy: Distance from nearest well-----------"_--------------- =._____Qistance from nearest building -------- Distance to nearesf lot line-_-_____...°-- ` Remodeling and/or repairing (describe);-__'__ - t,,,.�� 1 4 --------- --- --1------ ------------•---------- -----••---- ----•----------------- ---------- ------------- I. -------- = ----- -----•------ - ------- ---------------- --------•------ ----------•--------- -----•---------------------------- --- { -------•---------• - ----- ----------------------•• -- g -------•--------------------:------.------- ------•----- I hereby certify fhat I have prepa d this application'and fha the work will be done in accordance with-San Joaquin County 1 ordinances, State laws, and rules and regulations of fhe Sa Joa uin Local Health District.. ' (Signed). K-JI - -- - -- --- --- -------- ------- --- Ow er and Confractorj By:.- f e---- • ---- --- -- ----------- {Title}-- - --- -- ----------------- •------------------------------- - �--- . . -- ---------------- of plan, showing size`o lot, locafion of system in relation'fo wills, buildings, etc., can be place&on reverse side). FOR DEPARTMENT USE ONLY � Y APPLICATION ACCEPTED BY------- DATE f ------------------ REVIEWED BY__.. - - ------------ DATE------------- ----------------------------------------------------------- BUILDING PERMIT ISSUED-------------------I 4 ------------------------------------------------------- •------------------------ DATE-------------- Alterations ---=---------- -------------------------- and/or recommendations:- ------- -- -- -- -----------= == " �= '""�.. r------------------ r.,_ f-` ' ��A_ '------- � ' _ p �.°�' ` t , ` '- -- .. --------------------------- -------- er - -------------------------------------------------- ------------ ----------•------------------------------------------------------------------------------- - W --------------------------------- ---------------- - --- --------------------------------- FINAL INSPECTION BY: ------------------- Date-- . -----� .f 7 J - ---------------------- -- IVSAAN JOAQUIN LOCAL HEALTH DISTRICI JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C•' Street Stockton, California I Lodi, California Manteca, California Tracy. California ES-9-2M 10-52 Revised W-2100 ,;;