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APPLICATION FOR SANITATION PERMIT Permit No. (I ,✓� (Complete in Duplicate) ` . / / Date issued ---_ -3/S_�3 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 17 County Ordinance No. 549. JOB ADDRESS AND LO ATION---------�/._---� -------- ---------------- ---- -------------------•---- •----------- --------�--------�---_----�----/-------------- Owner's Name---- •------------------------------------------- ----------------------------------- Phone__22,=-`�------------- �S/G_-_ Address -- --- -- ---- -------------------------------------------------------------- ----- Contractor's Name-- • -----�q ?_ --------------------------------------------- ---------------------- Phone-'7• -0----4--- 4-.Z--4---- ------ ----- Installati ---- Installation will serve: Residence rK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __--__-_ Number of bedrooms ----d2 .� /;;6 Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table !�U_ ft. Character of soil to a depth of 3 feet: Sand [❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous .Application Made: Yes ❑ No g New Construction: Yes 9' No ❑ TYPE OF: INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from.nearest wellloW____-__Distance from foundation---/4 -------- .Material______________________________________________.. No, of compartments-------- -------------Size- -X_414--X_ __----Liquid depth_--- .-----------Capacity___ p-- - - �� //�� v OA- Disposal Field: Distance from nearest wei1�10_w.+4�4XDistance from foundation____dZ_��_____...Distance to nearest lot line___��_.�_... Number of lines__ Length of each line-----r3a_� _____________Width of trench____�_°�__�__._________- -.-___ J/' Type of filter material „" _____Depth of filter material--_./. _��_____._Total length-__.____. �_�______________._______ Seepage Pit: Distance to nearest well►w__W Distance from f undation____-!�D.___.__.Distance to nearest lot line___a7d Number of its______________________Linin material___ .______ �� p g Size: Qiameter ~ Depth a 5�------------------ Cesspool: Distance from nearest well-----------------Distance from foundation-----------------_:Lining material____-_._.________._________-______ ❑ Sizo: Diameter--------------------------------------Depth------------------------------ --- ------------ --Liquid Capacity---------------------------gals. Privy: Distance from nearest well _________________________._______.___.---------Distance from nearest building--____.____________---_-______._._.__..._. ❑ Distance to nearest lot line-----------------------------------------==--------------------------- Remodelingand/or repairing (describe):----------------- -------------------- --------------------------------------------------------- -------------------------------------------------------- ----------------------------------------------------- ------------------------------------ -----------------•--------------------------------------------------------•------------------------------------------------------------------------------------------------------------- I hereby 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 a d regulations of the San Joaquin Local Health District. (Signed)--- ----------- ---------------------------------------------------------- "':_ � ----------------------- ---- --(O er �,nd/or Contractor) I3y:------------ ,•�-----------------------------------------------(Title)- ---- - -- - - -- ----------- (Plot plan, showing size of lot, location of s em in relation to wells, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------------------- ' ------------------------------------- DATE------ ---,//" ---=,; REVIEWED BY ------ DATE-------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------- --------------------------------------------- DATE-------------------------- Alterations and/or recommendations----------- ----------------------------------------------------------------------------------------•--------------------•-------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------•----•-------------------------------------------------_•-------------•--•------------ ---------------------------------•-•-----------------------•----------------------•-•-- -----------------------------------------------------•-------------------------------------------------------------------------------- 's 3 - - Date-------- ----,/` FINAL INSPECTION BY----------- -------------•-------------- �G� - - ---- ------- ----------------------- - ---------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street ` Stockton, Califoinia Lodi, California Manteca, California Tracy, California ES-9--4M iD-52 Revised W-2100