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1� rK APPLICATION. FOR SANITATION PERMIT `� "3 Permit No. _..__ -. (Complete in Duplicate) r Date Issued �^___/.L• _� Applical,ion 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 No. 549. JOB ADDRESS AND LOCATION_- 1 --A�r t ----------------------- ---------------------------•-•------------------ --- j Owner's Name----------------------------------- -��-�'l�.Q--- ---- = -------- ----------- -- -- Phone- Address------------------------------------- oneAddress------------------------------------- -------- - ------------ U -- -- _- ---•------------------------------------------------------------ Contractor's Name------ •--------------------- - ---- ----- •- ----------------------•----------------------------------- Phone -•-� Installation will serve: Residence Apartment House ❑ Commercial F] Trailer Court E] Motal ❑ Other El Number of living units: _A.'___ Number of bedrooms -3. Number of baths _____ Lot size -� f ----- -------------•- Water Supply: Public system E_--c-,ommunity system ❑ Private ❑ Depth to Water Table _ ft. Character of soil to a depth of 3 feet: Sand ❑ avel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tic T-a�k-: Distance from nearest well----—_-_____-Distance from-foundation___-___-_________-Material_________-____-________________________________ gk� No. of compartmentsl----- -------------------Size-----------------------•-------Liquid depth--------------------------Capacity------------------=---- os�al Fie)d: Distance from nearest well_________________Distance from foundation----______________-Distance to nearest lot line----------------6 - ` �� Number_of lines-----------------------------------Length of each line-----------------------.-----Width of trench--------------------------------•-- Type of filter material-------------------------Depth of r ----. ---------------Total length------------------------------------------ :t F See age Pit: Distance to nearest welL_M_.Q_N_CZ_.--- tante fr m foundation _ �_____�.Distancdetto nearest lot lin�______t ------ Number of pits-----'---------------Lining m terial-(Ila ----Size: ameter--- -�--------Depth---�� ------------------ - Cesspool: Distance from nearest well-----------------D tante from found 'on---------------------Lining material-------------------------------------- ❑ Size: Diameter-------------------------------------Dep -------------- -------------------------- - --Liquid Capacity- -------------------------gals. i Privy: Distance from-nearest well------------------------------------------------Distance from nearest building-------------:------.--------------------. ❑ 'Distance to nearest lot line-------- ._ ------------------------------------------- -------------- ---------- Remodelingand/or repairing (describe)-------------------- ---------'-----------------------•--------•-- -------- • ----•--------- -•-----•------------------------------------------------ ~ I ,. ` T " — ------------•-------------------------------- ------------------------ = = -= --------------------------------------•------------•-•---------------- -----___--------•-•----------------------------------------------•-----------------•-------•-------------------------------- _ I herebyfy that I have prepared this appli ation and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules and gulations of the San Joaquin Local Health District. .(Sign r ------------- -- ----- ------'-- ------------- ' ---- -{ Cn- dContractor) r By: = = `` ---------------(Title) � �' (Plot plan, showing size of lot, location of system in r ation to wells, build' gs, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- __ DATE-; '----•------------------------------------------------ REVIEWED BY----------------------------- ------------------------ -------------------- - ------------------------_-- DATE---V------------•-•--------•---------------------------- BUILDING PERMIT ISSUED..------- -------------------------------- ----------=-----------•----------------------- DATE------trot Alterationsand/or recommendations-------------•------------------------------•-------------------•---------------•-----------------•--------------------------------------------------••------- ----------F•---------------------------------••------------------------ -----------------------•--------------•------------------------ -------------•-------------------------------------------------------•-------- � � I -----•------------ --------------------------- ---•---•--- - _ ---------------_---------___--------------------_--F_______-______-_____----------------------------.----------.----------------.------------------.---------------------------------------------------------------- i. FINALINSPECTION BY:_---------------------------------------------------------- Date------- - -------- . a-------------_ 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 Revised W-2100