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APPLICATION FOR SANITATION PERMIT Permit No. _ _ -- _ -- 16 ; 3 6 (Complete in Duplicate) Date Issued ------------- . ------ Application is hereby m de to he San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with CountyOr finance No. 549. JOB ADDRESS AN LOCATION ----- - -------------•-------------- ------ = Phone-------- ------ Owners Name---------- --- -1----- -------------- - -` Address------------------- - -- '•----------------------- --------"-- Contractor's Name--- -------- -------- ------------------- ----•--- - ------------ --- Phone----------------------------------- # otel Other E]LO Installation will serve: Residence Apartment House El Commercial- ❑ Trailer Court ❑ Number of living units: -- ---- Number of bedrooms ---2j- Number o aths j---- Lot size ------ Q Water Supply: ------------------ Public system ❑ Community system [I Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: SVnGravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑� 'r .. Previous Application Made: Yes ❑ No New Construction: Yes V No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: G (No septic tank or cesspool permitted if publicewer is available within 200 fett. 1 �} !� - Mate -` Septic ank: Distance from nearest welL_ !l_____-Distanc Gem found n____-_ _____ __ �P� xa Li uid de #h Capacity ----- No. of compartments-----------------f--Size q , __.Distance from foundation-TZ. Distance to nearest to li r Dispos Field: Distance from:nearest well _ _ �} -.Width of trench________/�/I '�"- r Number of lines------ ""_-- •----� -- - - Length of each line-7-f/-'-"-05-o r- -. R Type of filter materia_ __^� 17epth of filter material--------- Total length__________ ------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to•riearest lot line____.______.____- ❑ Number of pits--------------------Lining material-----------------------Size: Diameter--------•----- ------ Dept ----------- -------------- -- i 4 Cesspool: Distance from nearest well-----------------Distance from foundation__-__._-_-.______.Lining materia______-"-_________.-------------els. ❑ Liquid Capacity-------------------=------- • Size: Diameter---------------------------------------Depth----------- ------•--- ------------- ----------- -------9----- Privy: Distance from nearest well--------------------------- from nearest building_____.____-_____________--- ( ---------------------•- ❑ Distance to nearest lot line-----------------------------------------------------------------•----• --------------•------------ I Remodeling and/or repairing (describe):-----------•-"---------------------- --------------------------------------- •- -----------•------------------------------------------•-----------... -----------• -------------•-----------------------•-------------- ----------------------------•--------------------------- I •-__•.•_—.,�.• _ —-ter- . ... _... I hereby cert' that I have prepared t {s application and that the work will be done in accordance ; ith San Joaquin ounty ordinances, St a and ,ul stand a ions of the San Joaquin Local Health District. -----------------------(Owner and/or Contractor) (Signed}__ � -- - --- --- ------------------------------------------------------------ . By:------------------------------------------------------------------------------------- -------------------------------------------(T�ale)--------------------- --------------------------------------- (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-- - -------- --------------- -- ---------------------------------- DAT1 --.- REVIEWED BY . . ---• --------- DATE -ter ----- - -------------------------------------------------------------------------------- BUILDING PERMIT ISSUED -- ------- - ----------- = DATE ------------------ Alterations and/or recommendations:----------------------- ----------------------------- ------------------------------_ --•--------- --•-"------------------------------------- ---------------- ----------- -----------------_.. c FINAL INSPECTION BY:__�-"------------------ - Date--- .SAN JOAQUIN LOCAL HEALTH DISTRICT 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California I Lodi, California !Manteca, California y. F t ES-4--2M 8-51 Revised W-2100 W '