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r�:r p- APPLICATION FOR SANITATION PERMIT Permit No. .-S.2o_--__- 1 " x (Complete in Duplicate} _ Date Issued ._ Applica{ion is Hereby made to-the San Joaquin Local Health District fora permit to const uct and install the work herein described. This application is made in compliance with County Ordinance No. 549. 4 JOBADDRESS LOCATION i s h� . - ---- -- ---- ---------'----------:-----------------------------=----=------•-------------------------------- }�` -------- --- Phone------------------------------------ Owner's Name-- ..----- ----- _ Y Address . - -------• ----------- ---------=-_^----------------------------•--------------------------------------------------- -------------------------------------- Contractor's Name----- --------------------------------------------------------- ---- e Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Mots[ E] Othert ❑ I--- 7_6 � Number of living units: _�--- Number of bedrooms X- Number o baths ___I--_ Lot size ____--i-- ____�-�-�-+ -------------------------- Water Supply: -Public system '❑- Community system ❑ Private Depth to Watet Y Character of soil to a depth of 3 feet:' Sand Gravel ❑ Sandy Loam [] Clay Loam [I Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes'y(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------------------Material______________________________•_-___.._________-- NO. of compartments----- ------- ------------Size--------------------------------Liquid depth--------------------------Ca -------- Disposal Field: Distance from nearest well-___. ----- ,-.Distance from foundation____________________Distance to nearest lot line--------------_ ❑ Number of lines-------`-----------------------------Length of each line-------------------------------.Width of trench----------------------------- ----- Type o"filter material-------------------------Depth of filter material--------•--------:--•--Total length------------------------------------------ Distance to nearest well________________�__ `Distance from foundat.ion_--------------------Distance to nearest lot line------_-_-.__.__ El Number of-pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------- k 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__________.__---_____________________.__. ❑. 's Y y..e + _ ------ _ •�. -Distance to neatest lot 'ne--' -y-------=- -- --------------------------•-•-- -------------------------------------------------------------- -------- A ---- F ( ;+ e -- --- Remodeling and/or repairing (describe}�� _ _-_ -- { -- - - ----••---•------------------- ' S 5 { __ __-__ _____- __ ---------------- - ___________ xs'--------------"'- 4 — + — _ ___-----------_____-------------------------------____________ _____ _ ____. y. --- -- 'nom ----------'--------------------------------------------- --------------------------•------------------------------------ l _ I her by certify that hhav • e,�prepared +his application and that the work will be-done in accordance with San Joaquin County ordinances, 5 ` laws; and rules nd regulations'of the San Joaquin Local Health District.: pte } t - -------------------------------------------- (Signed) ------ ------ -----(Owner and/or Contractor) - ------------------------------------------a- a ------------ Title---------------=------------------------- ---------------------- BY� -----------•---------- --•-------- ------ ----- -- (Plot 4lan. showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). E FOR DEPARTMENT USE ONLY } l APPLICATION ACCEPTED BY_ DATE ------------------------------------------ REVIEWEDBY--------------------------------- ---- - --------------------------------------- ------------------ ATE BUILDINGPERMIT ISSUED------------- -------------------------- --------------------------=------------------------------- DATE Alterationsand/or recommendations---------------- -------------- ------ ---------------------------------------------------------------------- ------=--------------------------------------- ` ----------'------------------------- ------------------------••---------- .. ---------------------------------------------------------------:_:------•-•=--------••••------ -----------------------------•----------------•-- --•---------------------------------------------- ----------------------- --------------------------- ----FINAL INSPECTION . Date ` - ------•----------------- SAN JOAQ61N LOCAL HEALTH DISTRICT i 134 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California t 1 ES-4-2M Revised W-2100 — -�