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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) { Date Issued Applica}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 wi County Ordinance No. 549. / [' JOB ADDRESS AND LOCATIO "" f.�,�..,.,.r.�-�•z•t,�ss.- Owner's Name�_ f .__ L --------------- Phone r2r ------- ---- ------ t - 4. Address__.- -!01--•-- :.. � 1..�� ---------- Contractor's Name__._.. ____.--___ __r'�'� Installation will s40w;. residenc Apartment House E] Commercial ❑ Trailer�Cowt © Motel ❑ Other M Number units. __l---- Number of bedrooms _ __ Number of bathsti..-. Lot size ""�-"a._6____-^:.r ------------ r : Water Supply- 'Public+system ❑ Communify system ❑ Private.1J Depth to Water Table,�-.- --:ft. Character of soil to a depth of 3 feet: 'Sand ❑ Gravel ❑ Sandy Loam ❑ Cay Loam ❑ Clay ❑ AdobeJ11 Hardpan ❑ Previous Application Made: Yes ❑ No KI New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank,or cesspool permitted if public sewer is available within 200 feet.] U �. , - Septic Tank: Distance from nearest welk __Distance frpm foun .donoraterial_ _ Q_._"_._"_________. No. of compartments....,.................Size_"_AY_"--------_� -Liquid de th_ i ----------Capacity Disposal Fie)d: Distance from nearest well, . "".Distance from foundation_ -0 ---_.Distance to nearest lot Number of lines_______I___:_---- Length of each line____-- �-" .....__.Width of trench_-;! ._"- Type of filter materia l—----------Depth of filter material_.f "._ -Total length".60________________""_"""-_""""_"""-_ (� Seepage Pit: Distance to nearest well-----------------------Distance from foundation----------...._.....Distance to nearest lot line_..___.____.__... �V ❑ Number of.pits_ `-----------------Lining material--------------:-------Size: Diameter-----------------------.Depfn____---------------------------- Cesspool: Distance from nearest well---------:--------Distance from foundation ___________________Lining material-"-_-__.._.__.________".-"--.__._.-_ F Size. Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-__--------------------gals. e; Privy: Distance from nearest well """-__--__..-----------------------------------Distance from nearest building----------------------------- _"-"____. {� ❑ Distance to nearest lot`line..____._. - — =9(� 1 Remodeling and/or repairing (describe):_.___ C t _._ .--__`V----_fes, f --------------•----------------------------------------------------i -:-•--•--------------... -----------------------------------------------------------------------------------------•------------------------- -------------------------l i I+ereby-certify that I have-prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regula ions of the San Joaquin Local Health District. (Signed)_. 4- .�...__. "_.. ?w ------------------------------------------(Owner and/or Contractor) By:-----------------------------------------------------------------------------------------------------------------------------------(rtle)---------------------------•------ - - (Piot 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----- -A --------------------------------- REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE-------•--------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------•------ Alterations and/or recommendations:--W-----------------------------------------------------------------------------------------------------------------------•---...---------------------------- -------------------------------------------------•------------------ ----------------------------------------------•---------------------------------------------------------------•-------•-•------------------------------ ---------- ---------------------------------------------------- = -- ---------------------------------------------------------------------------------------•--------------------------------------------------------••-- t ------------------------------------------ ---- --------------------------------------------------------------------------------------------------•----------••---•--•--------------------------------------- u FINAL INSPECTION BY• . ----=------------------- Date-- -C.--- ?-' 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-9-21A ; Revised W-2100