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APPLICATION FOR SANITATION PERMIT Permit No. .__... (Complete in Duplicate) Date Issue Applica+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 Ordinancp No. 549. JOB ADDRESS AND LOC TION------ - .c , _-_ Owner's Name.----- ----- -- -- -- ----- -- -- -- = -- ------------ Phone r � N Address-------=----------------r- --�--- - -----�'�°-'�J- -•--- --- --- - ---- --- --------••-•----- -------...-------------------------...---•--•--••- -•-- --•- ---- r Contractor's Name-- ---- ------ -------------------• Pho :_ ' - Installation will serve: �Residence (] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other �`rJ 4 Number of living units: __/___ Number of bedrooms __ __ Number of baths -_ _ Lot size ___�".__ � -�+*.�-_________________________ Water'Supply: -Public'system [Community system [I Private ❑ Depth to Water Table _f=jj_ ft. Character of soil to a depth.of 3 feet: Sand Gravel E] Sandy Loam ❑ Clay Loam E] Clay E] Adobe[�]-Hardpan E]Previous Application Made: Yes E] N0 New Construction: Yes ER"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_____/J-----___ J-__ Distance from foundation___./d------__.Materia!_ - [?� No. of compartments-------6Z, _.Size_ 4_V_X_ J,_._Liquid depth-_._JZ_ ---------Capacity___ Disposal Field: Distance from nearest well....7J_'.__Distance from foundation____ __`___.Distance to nearest lot line____li�__,_ 1" ! [� Number of lines------------- -� g �-----------------Width of trench. �, 6 of each line------ -- Type of filter material/�_______ .____ __ Length t of filter material___.__ 1-_ .___ g �- Depth ----Total len #h ..2i --t--------------------- x l 4 Humber of its-------- -------- --Linin ma eriai Seepage Pit: Distance to nearest well-,A0.0 Dis - ce ro foun ---_ ______Distance to nearest lot line_ Number � g a e _Size Diameter___s,✓_.��._ -" ____.Depth_...1?��------------------- Cesspool: _-__ Cesspool: Distance from nearest well-----------------Dis rom oundation____________._.___..Lining material-------------------------------------- El _-----____.---_-----_-_-___-- --__.❑ Size. Diameter-----------------------•--------------Depth---- ----------------=------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------_-----------------------------Distance from nearest building__________.__.________________ ❑ Distance to nearest lot line------------------ --------------------------------------•----•--------------------------------------------------------•-----------r-------- Remodelingand/or repairing (describe)---------------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------- ------------------------------------------=-----------------••---------------------•---------------------•-----------------------•---------------------- --------------- -----------------y-------•-•----------------------------------------------------------------------------------------..........----------------------------------------------------------------...._...----------------------------- 4 -•--------- =--------=-------------------------- f-----------------------------------------------------------------------------------------------.------------- =-.?F!70------------------- 7 ` 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 reg u tions of the San Joaquin Local Health District. ---'----- ---------------------------------------------------------------------------------------�--s and/or Contractor (Signed]--=----•----�----- - / � ----- By: ----------------------------------•--.--------(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 r- APPLICATION ACCEPTED.BY-------------} - ----- DATE----------- = ------------1:5�y_ --------- REVIEWEDBY----------'--:------------ ------------------ ------------ ---------------------------------------------------- -•-------- DATE-------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------•---------------------------------------------------------- DATE-•-----------------•----------------•---------------------- -- Alterations and/or recommendations- - - ----------------------• -------------------•-•----•- ----------•------------------ ------------------ -- - - -- -------------- ------------------- � �. _.. -------------------------------- ---------•----------------------------------------------------••---•----------------f:.------ r �F ---•------•------------------------------------------------•------•----------------------------- -------------•---••----- •-------------------.-•-----•------------------------------------------------•-- -----------------------------------------------`----- ------------------------ --------------------•----------------------------------------------------I-------------- -----------_.................. -- ---- - �j �-- f �^ v f FINAL INSPECTION BY. r J`� �'1 1 !'-1 Date----------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street ,h Stockton, California Lodi, California Manteca, California Tracy, California `} ES-9-2M Revised W-2100