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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) 7 �i � Date Issued __-.-�. ..___5-______ 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 Ordinance No. 549. JOB ADDRESS AND ION__� ......./6-e------ ------�ja--•"_,__n_` mac--- -±rte---------- . ------------------- Owner's Name------------ V.4p_'_'_-d__•_, -----42.x-•----- __--1"" .. ,. Address �� ..... <`-------_, . .........................:..------......-----------------------•. ., t Contractor's Name �.. `"- ,- •----------------------------- Phonet 0----4-f-4 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [❑ Number of living units: J----- Number of bedrooms 1— Number of baths _ __ Lot size ----Z7_&'_�_/J_Q*_____________________ Water Supply: Public system 531olcommunity system ❑ Private.❑ Depth to Water Table _ ®ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe 20-.*Hardpan ❑ Previous Application Made: Yes ❑ No 2 r New Construction: Yes E] No E] TYPE OF INSTALLATION AND SPECIFICATIONS: - ` ' (No septic tank'or cesspool permitted.if public sewer is available within 200 feet.) tic Ta k• Distance-from nearest well-----------------Distance'from foundation_.__.-_.-----------Material,___________-__-____--______-______-__.__.______. No. of compartments--------------------------Size--------------------------------Liquid depth--------- ------ ---------Capacity-----------•----------- os Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----------------- Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------------------------- Type offilter material____- --------------_-Depth of filter material--------_--------------Total length__-__________________ Seepage Pi Distance fc nearest well-��97?-cE- ..Distance fro foundation___ ..___.Distance to nearest lot line----- __-_*__ Number of pits---__ __-------------Lining material__ - _ De to--____ -_ Size: Diameter___. -. 4. Cesspool: Distance from nearest well-----------------Distance from foundation-------------- ___ Lining material-------------------------------------- El ._ q� ❑ Size: Diameter---------------------- ------ -------Depth--------------------=--------------------=----------Liquid Capacity----------------------------gals. Privy:v ,Distance from nearest well---- .......... -- building------------------------------------------ ----------------------------- from nearest buildin ❑ .,_ -'Distance to nearest lot fine----------------------- -- •--------------------------------------- Remodeling and/or repairing (describe)_-------______________._ -_� ---------- -- ----------------- - --•---•-----------•----------•-------------- ---------------------------------------------------------------------------------------------------•-----•-•--•--•-------#------------•------------•--f--•-------•----••----------------•--------------------••---•------ ---- -------- - -- - - - I here certify at I have prep ed this application and that the work will be done in accordance with San Joaquin County ordinances, laws and rules and gulations of the San Joaquin Local Health District. (Signed) ---------------------- ------------------------------------------------.�(�� Contractor) By:------------------- ----------=------------------------------------------------------- •-------- ---------- - --------[Title)- - -&ZA- - ---- °`�-- -------------------- (Plot ^ (Plot plan, showing size'of lot,°location of system in relation o wells, buildings, c., can be pla end on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ------- - -------- -- ---------------------------------------- DATE—.---------------------------------- --------- REVIEWED BY - •`J - -- --------------:_-- =---------------- DATE---r -------------------------------- BUILDING ------------------------•---BUILDING PERMIT ISSUED---------------------------------- ------------------------------------•---• --- =------------ DATE--- - - r Alterations and/or recommendations----------------------------------- ---------. -----.....----••. •-------------------------------- -------------•--•------------------- -----------------------------------------------------=---------------------- - --------------------------------------------------•--•--------•---•--------•----------------•--•-------•--------•------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------•-----------------------------------------------I------------------------------- ----------•-------------•-------•------ ------•-------------------------------------------------------- ------------------------------------------ ------------- ----------------------.----------------•------------•------ - - - ----------- ---------•-- -------------•--------------------------------•-•---•-------------•-----••-----------------------------------•-------------------------------...------------ 4 FINAL INSPECTION BY:.- ----------------------------- Date . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100 _ rt