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fr , APPLICATION FOR SANITATION PERMIT Permit No: ... _ 3. ... nI _ (Complete m Duplicate) J_ � Date issued .__�__r_�_�_"53 San Joaquin Local Health District for permit to construct and install the work herein described. Application is hereby made to the Sa q p . This application is made in compliance with Coun y ina k7e No. 549. JOBADDRES AND LOCATION r- - --------- -------------- ----------•---- --- ---------------------------------------------------------- Owner's Na e_ - ______ ---------------- -- -----'..._..--- -- -- ---------- -------------•-:- -- ----- - -- ----------------.-----------------..Phone---j-----------r------------------- Address `t' ------------------- --------------- ---•-•-•--- ----------------------------•-•-------------------- --------------------------------------- ------------------------------ Contractors Name---- '-------- ---------- -- -----------------------------�f-------------- ------------------- -------------------------------------------- Phone.--.----------------------- Installation will serve: Residence Apartment House, ❑ .Commercial ❑ Trailer Court ❑ Moterl ❑ Of eS ❑ Number of living units. ___�___ umber of bedrom _ __ s __�_ Number of baths ___�_-_ Lot size ____ .g__X�_� � ° Water Supply: Public system • Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Lo;pNo ` Clay Loam ❑ Clay El Adobe 21-/Hardpan El Previous Application Made: Yes ❑ No 7New Constructions,: Yes ❑ , �] TYPE OF INSTALLATION AND SPECIFICATIONS: I [No septic tank for cesspool permitted if ublic ewer is available within 200 feet.] =� Septic ank: Distance from nearest wellak__' __ ��Distanc�.from foun�lation�:Q__________._. ateri I�________------------_--------- ______________ No� of compartments----------�_r_--- - Size_ --x Xc ------Liquid de th------_---�.-------.Capacity----- - -___-- Dis osa Field: Distance from nearest we�0__.`=' isi-ance from foundation_ __ __.Distance to nearest 1R,t IiJ�e�__�_______ V� t li 1 / !/`T'-- Number of lines_________ ----------- ________ _ ________ _Len th of each line_-__._____..___�>� Width of trench.__--_- - �r` g �f k f -- ----•-- Type of filter maters , flp J_ pth of4 filter materiai_____I- --------Total length__3__________�__r�1_�__.•__.______._ Seepage Pit: Distance to nearest well______________________Distance from foundation-_-..___________-...Distance to nearest lot ❑ line_..____._____--_. Number of its----------------------Liningmaterial_-_-�--______- - - . 5ize: Diameter---------------- Deetn------------------------------- -- Cesspool: Distance from nearest well foundation__________________.Linin materia -I---__------------______-__________ ❑ Size: Diameter--------------------------------- --- Depth---- ------------------------ ------------ --------Liuid Capacity - ------------------------gals. � Privy: Distance from nearest well----------------l-------------- .--------------Distance from nearest building--------------------------------------- If ❑ Disfance to nearest lot line- ----- ------- ----------------------------- -----------------•----------------------------------------------------•-------------------- ____________ _________________________________________________ ---------------.__.-_________-___.________________.__.__ 'yk Remodeling and/or repairing Idescribe)_______________________________ r ------------------------------------------•-----------------------------------•---- --------••--------------•- --------------------------......•--------------------------•----------•---•--------•----------------------- --------------- ------------ -----------------------------------------)--------------------------------------------------------t------------- I-----....---•--------------••-------------------------------------------------------------------------------- --------------------------------------- ------------------------------------------------------t ---------------------------------------------- 1 I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances State laws, and rules ndregula ions of the ISan Joaquin Local Health District. (Signed) - ----- _--- - � 't---`------.I- -------------------- --------------Owner and/or Contractor ---------------------------------------•---------------'------------------------------------------ --------(Title)--------------------------------------------------------------- (Plot pla , showing size f lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY = APPLICATIONACCEPTED BY --------------- ----•------------I-------• ------------------------------------ DATE- --------------------------------------------------- REVIEWEDBY------------ --- --. --------------- ------------------------------------- DATE- - BUILDINGPERMIT ISSIJED-----------7—----~------------------------- --------------- ---------------------------------- DATE---------(;&--------------------- - Alterationsand/or recommendations:----------------- ----- ---------------------•---•-------------------•--------•--------------------•---.----------------•------------- -------------------------------•--------------------•-------•------------------------------ ------ -------------------------------------------------------------------------------------------------------------•------- 3 4 ------------------------------------------------------------ --- FINAL INSPECTION BY: __ ; Date------ - :_.L_ _---�------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRIC 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M 10-52 Revised W-2100