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4 APPLICATION FOR SANITATION PERMIT Permit No.,S- i-•(---p- r` (Camp[ete in Duplicate] Date Issued P/0/, 6- �Z._ Applica4-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 Ordinance No. 549. y JOBADDRESS AND OCAT ON.- "'� {O I ...... _ .-R-------•--------------------------------------------------------------------------------- , ✓> .P-�- ------ •• - - --------- -- --- -----------------•----------------- Phone' s Owner's Name____ _ -- ---------- - r Address-.---;?..P�_ 7-------P...--- ------- --------- ---------------------------------------------------------------------------------------------------------------------------••-- Contractor's Name ` Phone ___-_-- ice"''------------ Instaliation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel r❑ Other ❑ Number of living units: ,,I- Number of bedrooms J--- Number of baths J--- Lot size ______SP r_____C_/-t? ____________________________ Water Supply: Public system P9"Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ [� Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ J� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) `r Septic Tank: Distance from nearest well__ ___________ Distance from foundation._C 0_ ____--.Material_.___ Cly xNo. of compartments-------.-----------size--- -----Liquid depth-------5--------------Capacity__--------- -dv Dis osaI Field: Distance from nearest we11__,C"Distance from foundation__15f1---------Distance to nearest lot lin``e��_._ Number of lines--------------- Length of each line---�S f'__.-------Width of trench----------Z�"--------------- Type of filter material,c!;�/21-115Lr.,-------Depth of filter material----f,? ---------Total length_____________7__�_-(CKD Seepage Pit: Distance to nearest well----------------------Distance from foundation---------------Distance to nearest lot line_______________-- ❑ Number of pits----------------------Lining material:----------------------Size: Diameter------------------------Dept h--------------.------------------� Cesspool: Distance from nearest well-----------------Distance from foundation___-----------------Lining material__._______________________-____ -- ❑ Size: Diameter-�--------------------------- -------Depth----------------------------------------------------Liquid Capacity- - ------------------------9a s. Privy: Distance from nearest well__________________________________________________Distance from nearest building______________________________-_---- ❑ Distance to nearest lot line---------------------------------------------------------------- ---------------------------------------------------------------------------- Remodelingand/or repairing (describe)---------------------------------------------------------------•-----------------------------------------------•----•------------------------------------ -------------------------------------------------------------------------------------------- •---•--------------------------------------•--------•----------------------------------•-----------•---•-•----------------•- + ----- ---------------------------------------------------------------•-----------------•----------------------------------------••---------------------------------•----------------•-- 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 and regulations of the San Joaquin Local Health District. _ Owner and/or Contractor Si ned 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 APPLICATION ACCEPTED BY______ _______._.___._ ___ -. DATE-------------fd { ------------- REVIEWEDBY------------------------------------ ------------------------------------------ DATE------- ----- BUILDiNGPERMIT ISSUED------------------------ ---------------------------------------- DATE------------------------------------------ Alterationsand/or recommendations------------------------------------------------------------=-------------------------------------------------------------- ---------•-----------•------------•- ------------------••-----------•--------------------------------------------------------------------------------•----------------------•-----------------•-----------------------------••---------•----------•------------ - ------------------------------ -------------------------------- ------------------------------------------------------------•--------------------------------------------• -----•------ - ----------------------- ---------------- ------- - ---------------------------------------------------------- ------------------------------------------- ----------------------- -------•----------------------------------- FINAL INSPECTION BY: --------------------•-•-•--- Date------CJ-------------;-----•-- ----------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South AnTerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100