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APPLICATION FOR SANITATION PERMIT Permit No.�.�!----.- (Complete in Duplicate) Date Issued Application is here y made to the San Joaquin LocaltHealfh District for a permit to construct and install the work herein described. This application is made in compliance wa#h County ; .dinance No. 549. JOB ADDRESS AND LOCATION.. ___ ----- ------ Owner's Name-- -a,_ -.I --- -/C.c.�.a�C.t.-- f -- ---------------- Phone. Address_ •-------------•------ _ ..� -• - Contractor's Name-------------------------- [ �y p Phone ------------- r+. ----- -------------------------------------------------------- Installation will serve: Residence' Apartment House Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of livingunits: - __ l�umber of bedrooms _`!)—Number Number of baths .�__-- Lot size -_-_-_--_ _S-.,X__�-S O Water Supply: Public system 14 �ommu y system ❑ ]Private ❑ Depth-to Water Table -------- ft. Character of soil s depth of 3'feet: Sand ❑I 1\ } Gravel Sandy Loam-D.—C1ay,Loarn E] Clay ❑ Adobe[ Hardpan ❑ Previous Application;Made: Yes ❑ No.,� New Construction: Yes No r ms s..E 7 {{ !LOX � s� � ❑ TYPE; OF INSTAIILA: il!ON AND SPECIFICATIONS-.\ f {No septiclfank or cesspool permitted if public sewer is available wit Mn 200 feet.} Se tic Tan k: Distance from nearest well--_---------Distance from foundation-----t-0---------Material--------------- N,o of comparFments---• ---------Size--------------------------------Liquid Depth- ----------------�Capacity �x I N P Y Di o al Field: Dis afance from-riea�est,well--_,`~' Distance from fou-nclanion- _ _ __!____,Distance to Barest lot line------ �� _ Number of lines---------- _ Len th of each line._-_____- + i R . I -a._ .. �. ,r� e g ------------Width of trench. 2- ............ 4 Type`ot filter4mf#atenal-.--- ....--gip p h of filter material---_____. j )9------Total length--------------- `Z a - -- ---------------- Seepage Pit: Distance to rr"ea e f well_-_---__-------------Distance from foundation------------..------Distance to nearest lot line Seepage I Number of pits - ---�---------Lining material------------- ------ Size: Diameter-- -------------- Depth Cess ob'I ' +1 '_T ` 9 P f?istan4arom,nl�red well---------------_-Distance from foundation---- _--._______Lining material-_.---_.--__----_-_. Ef Size: Distance e'Diameter Weare-- well--------------------�epfh--------------------- ---------------- -- - Liquid Capacity----.-----------------------gals. Priv i --.-Distance from nearest b0clin ❑ Distance to nearest ot'line_�-------------- -- -------- -- -- - ----------------------------- Remodeling and/or repairing (clescribi):----------- ------------- j --------------------------- --1 ------------------ - ---------- ------- ----- ------------ --- -- ----- I lut -------•----- --------- --------------•--------------•------------------•-------•---•----------------------•----•----------------------------- - t herebycert ----------------------------•------------- -------------------------------------------------------------------------------------- x-• 'r lfy that I have prepared this application and that the work will be done in accordance with San Joaquin ordinances, StateIlaws, and rules and regulations of the San Joaquin Local Health District. 9 County i (Signed) 6 r-----l __t------_--_ _ " • (Owner and/or Contractor) y Y:--------- ---------------•---------------•---- - ----------------- ------------------------------------------------(Title)--------- (Plot plan, showing size of lot, location of system inrelatio'n to wells, #iuildings;-etc.;can:'be placed on reverse side). t F=OR DEPARTMENT USE ONLY' 1. APPLIZEVIEIW, TIONtACCEPTED By ----- ---- ------ DAT ,. --�:4 ED BY " DATE ----- �.--... ---------- ---------------------------- - BUILDIHG PERMIT ISSUED-------------.----_-_____-_--- --------------------- ---------- DATE ------ Alterafi ns and/or recommendations:—L_= _..m,,,.:,.�-_ '-------- -------------------------•---•----------------------------------------------------------------------------------------------- ---------------------------------•-------•---------------------•------1------------------------------------ --- -- ----- ----------- A -14 FINAL INSPECTION BY_____________________ •-- ------- 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 E5-9-2M r0-52 Revised W-2100