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nAPPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued Application is hereby made'to the San Joaquin Local Health District for a permit to construct and install the work herein described. with County Ordinance No. 549. . . ----------- This application Is made in compliance:i ,• ------------- ------------- JOB ADDRESS AND LOCATION-__- ---�-,--- ' --------------- --------------------------- Phone- --•-------- ---------------------- Owner's Name---------------------- ----------- ° ..-� a-...�-------------------------- -----=----------------.--- -----....-----"------------- --------------- Address--------•------------------••-------------------- ' ------------------------------------------------- •- Phone---------------------------------- Contractor's Name---------------------------------•----------------•---- ----- • �' 'f''J Motel Other Installation will serve: Residence X Apartment House ❑ Commercial ❑ T?a�ler Court ❑ ❑ ❑ Number of living units: _ -_ Number of bedrooms _-_P-Number of baths __A-: Lot size�- . +---- -- -,� Water Supply: Public system Community system ElPrivate ❑ Depth to Water --_:----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [I Clay L am El Clay ❑ AdobeR] Hardpan ❑ r r Previous Application Made: Yes ❑ ,No ❑, New Construction: Yes ❑ No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance 'from rtes_res"t well-----------------Distance from foundation-__--.__--------.MateriaL--__------.------------------------- p..par4e.. '_� ------Size------------------------------- Liquid depth -= Capacity pis❑oral Field: Dcstance from neo est well:___- istance from foundation- _Distance to nearest lot line_�J.-----.--- tJo. of com arta •' p _Q j_-__.Width ,of trench------r'_-�--� ------------- ® , Nb mber of lines_-t.------D-vl-__ _-_-- .Length of each line-_------� - Yp r material - ----- P De th of filter material------ -- t otal. eng#h-:-.----._--��------- Seep ge Pit. r Distance of to nearest well---------------------- Distance from foundation-----.------.----_sDlstance to nearest lot line_---.---------- - et �. Lining materia--- ---Size: Diameto4-----------------------Deptn-. ❑ N�mbar of pits-'-'------------------ f.� � � - - � i Cesspool: Distance from nearest well--------- f_:Di%ta,rtc%*Vrorn foundation------- ----Linin material-------- -------------------------- ISize: Diameter____ ______________ 1 \--1 :--.---Liquid Ca Capacity gals 1 ❑ , • � p Y ' rt Distance from nearest well :..-__---DepthE_--'�` ---- Distance from nearest building---------------- _---- Privy: : ❑ #o nearest lot line------------- - ------ Distance = - �` - I - ,-.- --- - Remodeling and/or repair [describe]:-._--..-_--- -- - - - --`-- I -------------------•'-------------------------___--_.-- --•_-�----__••_-___-••_-__._---_--_•___:_-----•__- E ----.----------------_--------- .. -._--- -- ------------------•----------------------------------------- - - ..,--.-y'----""_-'.--_-••-_-___--_-••-•---------------------------------•--------_..r------ter" --,---- --d . --_--.___----__---__--- I hereby certify that I have prepared this application and fife #lie work will be done nn,accardance with San Joaquin County i ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. • r ------------------- ---------.(Owner and/or Contractor) -----•--- -- -- � (Signed f ------------- --------------------- ----------- (Title) gY: , - (Plot plan, showing size of lot, location of system in relation" to wells, buildings, c„ aan be placed on reverse side. i. FOR DEP RTM,ENT US •ONLY 12 DATE APPLICATION ACCEPTED BY------- -- e---. - REVIEWED BY---------------------•---------- --------=---"-------: i------ DA ---7- -------/--------- TE BUILDING PERMIT ISSUED. - -------------------------- DATE =----------------- ---------------------------------- Alterations and/or recommendations------------_--------- --------- ----------------- ------------------- -------------------------------------------------------------•----- _ --------------------- -, FINAL INSPECTION BY:..-------- -- - ------ ----------------------------------- Date-" - -- -- -------- ------------------------= SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street /California Stockton, California Lodi, California Manteca, CaliforniaTracy,. ,A-9-2M I0-52 Revised W-2100