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APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) 4 Date Issued -/b-:- - 5_►'Z Application is hereby made to the San-Joaquin Local Health District for a permit to construct and install the work herein described. s This application is made in compliance with County,O,rdinance No 549 JOBADDRESS AND LOCATION----------- ---------- ------ ---------------------------------------------------------------------------- Owner's Name_----------------------- r......... � '- -------- - --- --- ------------------------ •-------------- Phone-------------------------- --------- Address_ 6 I-4 � ---------- ---------- -------- ---------------------------------- - - Contractor's Name =z `' ---- ------" �� t��4r � ✓_ 1•= Phone_...-: �i Installation will serve: Residence °Apartment House ❑t,..Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . / ,) Number of living units: / It]umber of bedrooms __ __ - Number of baths ---- Lot size __________________________________ Water Supply: Public system []Community sy fem-°❑ Private-E] -Depth to Water Table.3_____ �ft. Character of soil to a.depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ -[ay Loam E] Clay E] ,Adobe 4. H, ardpan El r Previous Application Made: Yes E] WN New Construction: Yes No El 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-----------------Distance from foundafion----_______-.:_.---.Material------------------------------------------------- f q�)(.c,i?--'"� No, of compartments--------------------=-----Size---------------------------------Liquid depth--------------------------Capacity---•----------------... Disposa€ Fi Distance from nearest well_�,�lT�--Distance from foundation------G---------Distance to nearest lot line--- Number of lines----- ----------- ----- `---Length of each line____-- _C f_------Width of trench-_--_-j __.----_-----_--___---- Type of filter material �f/11, Z---Depth of filfer material--- ----- --- ---Total length.__. __-__-_-___..__.__-- -_-_-__-_ Seepage PA Distance to nearest.well_IW-��`�_fi__Distance f ,m+ foun ation---- ____-_-.Distance to nearest to-h --- E - 0 Number of pits___ _ _„'_----Lining material_, lu�_R ni:, 46ize: Diameter_____--.-La---------.Dep th-_--_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------.-_-............ .___-. ❑ Size: Diameter----•-----•---------------------------Depth------ ----------- -.--------------------------------Liquid Capacity----------------------_-----gals. r Privy: Distance from nearest well -__-________________________----_--_--_`-_Distance from nearest building-----------------------------------.------ . ❑ Disfance to nearest lot line-----------------_---------------------------------------------------------------------------------•-------------------------------------- 1 I Remodeling and/or repairing (describe):------------------------- -----4-------------=----•-----------------------•------•-•----•--------••---------------------- ------• -------.....------------------- -------------------------------------- ......--•-------------------------------------------------------------------------------------------------------------------- --------------------------------- ----------------------------------------------------------------------•----•------- ---------,-----------------------------------------------------------------------------------------------------------------------------•- ------------------•-- -------------------------------------.....------------•-- ----------- --------------------------------------------------•------------------------ ---------;----------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ] ordinances, State I9,WS, and rules and ulation 'of;the San Joaquin Loca Health District. 5i ned - �----- `ran .or Contractor] - Ti+le4r.�� ?a -- (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----=-=------- ------------------- - - - - -- ------------- ---------------- DATE-------- ; �� - ------ REVIEWEDBY------------------------------------------- ----------------- - -• - - - ----- ------ ---------------- DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------- --------------------------- ---------.----- DATE-------------------------------- - EAlterations and/ar reccrnmendai-ions:- -------------------------------------- ---------------------- ------------------------------------------------------------------------------------------- . ----.� -- r k --„ ---------------- -------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- -----•-'-----------------------------' ---------------------------------------------------.--------------------------------------------------------------- -------------------------------------------------------------• -------------- A> � FINAL INSPECTION BY: = Date _hOrir ----------------------------------------- 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 ES-9-2M 8-51 Revised W-2100. f f