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� APPLICATION FOR SANITATION PERMIT Permit No. f Complete in Duplicate) Date issued ------ ------ -- -j Application 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 N 549. JOB ADDRESS AND LOCAT ON--- -------- ----'--_4- ++�----- - f Owner's Name---- -------- ------- ------------------------------------------- -------- Phone--- '" F -------- ---- -------- •--- �` ------ - = 1 Contractor's Name------ ------------------ -- ----------------------------------------------- ---"--------- Phone---------------------------------- Instal.lafion -------------Installa+ion will serve: Residence ❑ Apartment House g Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _7-___ Number of bedrooms ZQ_ Number of baths _7____ Lot size ______________________________________________-__-_._.___-_ - Water Supply: Public system ❑ Community system �❑ Private Depth to Water Table �69 ft. I Character of soil to a depth of 3 Sand E] Gravel E] Sandy Loam ❑ �C aT cam C haf❑�Adolae❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No sep+ic:+ank'or cesspool permitted-if-public sewer-is,available.within_200.fee#.}. p Ir 4 ys. Se tic T k: Distance from nearest well------- from foundation_____�0-_Materiae________________---------------_______________ No. of compartments-__ ______._____-Size___:�Y��--____-_____Liquid depth-.------ Capacity_/- 011__ Disposal Field: Distance from nearest well____171.`;_-Distance from foundafio "__�_l�7 Distance to nearest loft ling----------------- --______� Number of lines________________ _________ :_Length of each line:__ _ _-----------------Width of trench___ ______ Type of filter material--,_-V< Depth of filter material-------1.._II___--Total length------------------------------------------ - 1_ Seepage Pit: Distance to nearest welL _Distance from foundation___ ----_-.:Distance to nearest lot line_______________ ❑ Number of pits---------------------Lining rriaterial--------------_--------Size: Diameter-----------•-----------Depth-------------------------------- Ces'spool: Distance from nearest well--------------------Distance from foundation---------------------Lining material-------------------------,Y__________ ❑ Size: Diameter--------------------------------- ----Depth____ -------------------------------------- liquid Capacity- ------ ------ gals. Privy Distance from' nearest well---------------------------------------_ _____ -Dista from nearest building_: ,- ------------ Distanceto nearest lot line------------- ---------------;•----------"---- ----------=----------------------------------------------------------•----------------------- ' e 4 Remodeling and/or repairing (describe):--- ---------------------------------------------------------------=--------••----------------- ----------- 5. ------•-----------------------------------------------------------------•-----------•-•------------------------------------------------------------------------------------------------------------------------ - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Statlaws, and rules and-regulations of the San Joaquin Local Health District. (Signed) ---f --- -------------------------- --------------------------------------------- -----(Owner and/or Contractor) ------------ --- - ----------- -------- - -- - ------ ------------- -------------------- -------------------------------- ------- �. �- =y.•� BY�-=------------------------------------�-----•:-�--------:---- --- -;-,-- - - -_-� r -(Title} . _�". (plot plan, showing size of lot, Iota+ion of sys+em in relation to wells,'buildings, a+c., can be-placed on'reverse side}. FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---=- •--- -- ---------••-------- ----------•---'---- --------------------------------- DATE------- --------------- -------- - -- --- REVIEWEDBY----------------------------------------- -- ------------- ---------------------------------------------------------------- DATE--------------------------------------------•• ---------- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------•--------------------------- DATE.------------------------------------------------------------ Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------.....-------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------••--•---------------------------•- ---------------•------------------------------------------_-------------------------------------------•--- -------- ------------ -------------------•--------------------------------------------- ----------------------------------------- -- - --------------------------------------------___----------------------------- ---------...... FINALINSPECTION BY: --- ------------------- ---------------------------- -t Date-----------'------------- ---- ------- SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Street 300 Was+ 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 ejo, ' ' � G ' 4