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APPLICATION FOR SANITATION PERMIT Permit No.J- _ . ..... � (Complete in Duplicate) Date Issue,* __,�-f" AppliCa{on 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 Cou ty Ordinance No. 549. �"] E JOB ADDRESS AND LOCATION___ �._--1---�__'---.-___- r_-- . - __�--•-- -, - , Owner's. --- Name------------------- -- Phone s , r•^—em ----------------------------•---------------------------------------- --•--------------------_----- -------- Addres Contractor's Name -------- ----------------- Phone----- Installation will serve: 'Residence Apartment House p Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms __- baths Lot size�-_)e__-l —__Q-----------__ Water Supply:' •Public system R__�C` //ommunity system ❑ Private ❑^ Depth to Water Table ` "U_ ft. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam ❑ Clay ❑ Adobe9j—Hardpan ❑ Previous Application Made: Yes ❑ No Eg" New Construction: Yes ❑ No p TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) it Ta k istance from nearest well_________________Distance from foundation_ :_..__:_.__._.Material------------ .__________ No. of compartmenhs....----------------------Size-----.-_---------------f--,=Liquid depth-------------------- - Ca pacify osal d: Distance from nearest well------------- from fou dation--------------'__._.Distance to nearest lot line________-_____--- �'� Number of lines----- ` ------ ------ t ' Length of each line - Width of trench Type of filter matenaL_. "_ ._____.__:_.- Depth'Of filter material------------- ------Total length__________________________________________ s �� /r .--- -� : Seeppe Pit: Distance to nearest well-"-, Distant fro fo ndation---:_-------------Distance to nearest to line_____________ Number of pits-----/;______._.__-FI"ining material_ _ - Size: Diameter____ I � .--------:Depth---�-�----- ------------- Cesspool: Distance from nearest well----- ---------Distance from foundation_""_--------".__.Lining material_________________________________ El Depth ---- 6 Size: Diameter <R -----------Liquid Capacity----------------------------gals. PrivfromiP , -. Privy!, Distance nearest well____-----------------------------------------------Distanee-from nearest building---------------------------------------- ❑ Disfiance to nearest lot line__ _ ____________mac i _- _-. r - Remodeling and/or repairing (describe: -------__.'_-_ " " ----------------------------------•------------ ------•----- j4 E - - _____________________________------------------------ ----------------------------------- -----------------------------------------------•------------------ ----------------=---•-----• ----------------------------_---------------------------------------------------------------•--------- g ------- --------------------------- � I herebPat tify that have repared-+his;application and that the work will be done in accordance with San Joaquin County ordinances, laws, and rules d regula+ions of the San Joaquin Local Health District.(Signed)._ C t t_____ _____ 4 -- ------------------------ ` By:--------------------------------- -----_-` � on a __ _{Title]_ �__ r-------------------- inr - - - - - --- ------•-----[Plot plan, showg size of lot, location of systern in ation to wells, build' gs, etc., can be placed on reverse side]: FOR DEPARTMENT.USE ONLY APPLICATION ACCEPTED BY---------- '---------------------- DATE----- - ------------- - - - . . . --------------------------- REVIEWED BY-------------------------- ---- ---- --- --=-- ---~--�.------ - �� - DATE .-------I-----= ------------------••------------------ --------------=------------------------------------------ $UlLDING PERMIT ISSUED ---------------------------- DATE:----------------------- ` Alterations and/or recommendations: --------- ---- --------------------------•------ -------------------•----•----•--------.------------ 1 -------------- ----------------•--------------------------------•-----------•-------------------_. -- .--- ------------------------------- ' r � -----•-•--------------------•-•-----------------------,..------------------------------------ ---- 1 •---- - ------------------ --------------------------------------------_--------------_--- -----------------__------- -------------------------------------________________________________________________________________________-_______.______-_-_____ FINAL- INSPECTION-BY:____ � •ice Q ,_----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4-2M Revised W-2100 I l