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SANITATION PERMIT Permit No. APPLICATION FOR 5 --�--�--�---- ?- li D i t C ( omplee n. upcate) n� _ Date issued . f. Apl5lication is hereby made to the,-an�"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. JOB ADDRESS AND LOCATION-----�-t47,2 ----7-------- -------------------- ------------------------------ Owner's Name---------------_ "'..'_'- �J-- �" :. .- ----------- "' Phone Address-------------------- -----------------------•---------------------•------------------------------------7....... Contractor s Name-----�--------------•-------------------------- ,��3�-.-------- -----------•--------- -------------------- -----------•---- _ Phone----------------------------------- I � Installation will serve: fResidence,' Apartment House F1 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms. N,umbee..of,�baths,„. Lof sib=--------------------------- �/ 1 `ev Water Supply: Public system +< Communi4%system ❑ Private ❑ Depth to Water Table -------- ft. I Character of soil to a depth of 3 feet: Sands Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ac obHardpan ❑ ` Previous Application Made: Yes ElNo ElI NA Construction: Yes ❑ No El TYPE OF INSTALLATION AND SPECIFICATlONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) SeKiank: Distance from nearest well______ _______'_Distance fr:dm foundation.-_�;--------_M�tenial_____---_______-_-.________---------------------. No. of compartments---- I------------------ Size------------------ - Liquid depth ------- ---------- Capacity Dis o I Field: Distance from nearest weli__.__ ___ -Distance from foundation._ -- ~---b.istance to nearest lot line___._____- �[?_'!:-+.Width of trench.---------:�--`.r---------- Number o1 lines_____________ x -�7"""`tength o of ach line________-____ y /} �i jj Type of filter mattenaL _ :_lti/trQDepth of filter material___. --- length___ ----------------- Distance ------- I I Seepage Pit: Distance to nearet well_____________________Distance from foundation--------------------Distance to nearest lot line___._____________ ❑ Size: Diameter- ------------------.De th-------------- ------ Number of its-----:----A----------Lintng material --- t t P Cesspool: Distance from neares+'well_________________Distance from foundation--- Lining material_________.._____._-------------- ❑ Sizu: Diamet r ----- i.----------------------Depth---------------------------•`-----------'--- ------Liquid Capacify---------------------------gals. ' c Privy: Distance fro nearest well_______._________________________________ ____Distance from nearest building__-______._---__________-----. °� ❑ Distance to nearest 1pt#line------------------- --------------------- ..--------------------1------------------------------------ Remodeling and/or repairing (describe)------------------- ----------------------------------------------•--------------------- •------------------------- 9 --------------------------- i ! w l ---- e - iy ----- --- -----------------------------------------------------------------------•-•-------------------------------------------'----------------- ------------- --- h --- -------- I hereby certify it I have prepared this application and that the work will be done in accordance witli San Joaquin County ordinances, State laws, and rules andregulations of the San Joaquin Local Health District. 1 (Signed)_.___ A�,_T_A nl� _11�*4A------------------------------------------------ -------------------------- ______________(Owner and/or Contractor) Tale ---- ---•-••------------ `-------------------------,-------------------------------------------- (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------------- -- ----- ------ ------------------- t .— REVIEWEDBY----------#------------------------ ------------------------ DATE-----------•--------_-.----------------------------•------- BUILDINGPERMIT ISSUED--------------------------- - -- DATE.-----------------------------------------------------------• Alterations and/or recommendations:4------_------..�•-- _.�,. �------------------------------ -----------------•------------------------------------•------------------------------ 1 -----------------------••-•------.._...--------------------------------- ------ ------- ------------------------- - ------------------------------------------------------------------------------------ --- --------------------------- --------------------------- -------- ------------------------------------------------------------•- ----.. -------------------------------- ------------------------•------------------------•------------------------------------------- I7 Z7------------------------------- FINAL INSPECTION BY------- ---------- -- -- --- ------ - ------ Date.------------.. - FINAL I -- -- ` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street, 014 North "C” Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9—•2M 10-52 Revised W-2100