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AP � g PLICATION FOR SANITATION PERMIT Permit No.a a__4. Jill 0 l w (Complete in Duplicate) pate Issued�� _? .. �� : Application is hereby made fo'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 LOCATION_, 0 5--. ._ - i - �j Owner's Name------------------- E -------- -c-'725--- - --------------------------------- - -------- Phone__-.0-7d-4_'_�.-_'� . Address----------------_----- Contractor's --------- ------••----Contractor's Name-----------------••---_---- -�. _.. •---------•----•--------- —r-------------------------------------------=--------------------- Phone---- Installation will serve: Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _!___TNumber of bedrooms __.�'_ Number of baths J---- Lot size __-_ -- _- -------------------------- Water Supply: Public system 0 Community system ❑ Privateg Depth to Water Table _1�4oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobaX Hardpan ❑ Previous Application Made: Yes ❑ No 0 New Construction: Yes ❑ No ❑ �i ,., - , , ----TYPE-,OF INSTALLATION AND SPECIFICATIONS: (No septic tank-or cesspool permitted rif.pudic sewer is available-wi#hin 200;fee+.). T ec an Distance from nearest well________________Distance from foundation__.----------------_Material _____-----_______________--_.______f_______... No. of compartments Size Liquid depth------------------------- Capacity------ ---------------- D osall Fie d: Distance from nearest well-----------------Distance from foundation___________________Distance to nearest lot line________-_____-- e®�d Number of lines------------------------- ----------Length of each line------------------------------Width of trench- ------------------ ----------- Type of filter material-------------------------De t oaf-Filte Tial----_------------------Total length--------------------- _ p - -_ _ -----------•--------- Seepage Pit: Distance to nearest well --------- 'stanc f fo dati n____f�_-_•�-.Distance to nearest 1- line__.' r . [ Number of pits______-----------Lining m terial -.S' e: Diameter&-ca...........Depth__-- _- --------------- Cesspool: Distance from nearest well-----------------Di n from ndation--------------------Lining material_______.__.___.-____-________:___ ❑ Size: Diameter-------------------------- -----------Depth---------------------------------------- -- -------Liquid Capacity---------------------------- gals. Privy: Distance from nearest well-------------------------.-----------------------Distance from nearest building----- ------------------------- ❑ Distance to nearest lot.line-----------------------•------------------------------------------------------ Remodeling and/or repairing Idescribe)---------- -------------------------------------------------•-------------------------------- T .----------•---•--••----------------- =•---=•--•---------------•-------•------------------------------------------•-------------------------- ----- `. ------------------------------------ - --------------------------- ---------------- --------•-----------------------•----------------------------------------•--------------------------------------------------------------------------------------- I hereby.,certif +ha+ l have prepared thisapplication and that the work will be done in accordance with San Joaquin County _ ordinances, Siate laws and rules a d regulatto s of the San Joaquin Local Health District. (Signed) - -_, .-------------------------------------------------- -----------(6y/br Contractor] BY:== = ----•------ �' � = (Title) r C ,� { ) - �>- '{Plot plan;-showing si of lot. location-of'system'-in relation. o;,wells,`.buildings,,e+c.`,-scan be_paced-on_reverse side}. ..r •w_ y y a_ �- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------------------- - ---------- DATE— CPN REVIEWED BY-------------------------------- - DATE----,-2 .---------- ------------•--•------------------- BUILDING PERMIT ISSUED------------ 7-1---------------------------------------------------------------------------------- DATE----- ----- A terations and/or recommendations:-------------------•--------- ---- ----------------------------- ------------- ---------------•--------------------------------------------------------------•------------------------ ------------------------------------------------ ----------------------------------•-------•--------------•----------------••------------------ --------------•--• -----------------•------------------------------ -------------------------------•-------------------------------------------------------------------------------------••------------------------ ---------------------------------------------------------------------------------------------------------- -------------- P FINAL INSPECTION BY----------------------•----f•-fi --------- --`--- -- ------�- - Date-• --�--�- --.�__� 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 io-s2 Revised W-2100