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f . APPLICATION FOR SANITATION PERMIT Permit No. x� (Complete in Duplicate) ! Cl' ,! C Date Issued ._.. _ ealth District for a permit to construct and install the work herein described. Application is hereby made to the San Joaquin Local H ( This application is made in compliance with County Ordinanc No. 549. / --- -----------------• ------------------------•-------------------•-------------------- JOB ADDRESS AND LOCATIO _...___(�--------- -- ------ -------- Phone - -------------------------------- Owner's Name-----------•--------- - = __i__ ____ _.-.`~ _»__ ___ ------------------------------------ Owner's --------.--------_._" Add ress -------------------------------•------ ------------------------------------- ' Contractor's "Name---------------- ------- Phone Installation will serve: Residence �p artment House?Com er�ial ❑ Trailer Court ❑ Motel ❑ Other ❑ { Number of livingunits- ,�. � -) -0 ts: {__.__ Number of bedroom:.: Nu v er of baths ._..___ Lot size _____ __ _____________ r Water Supply: Public system ❑ Community. system ❑ r Private epth to Water Table ---_---. ft. Character of soil to a depth of 3 feet:: Sand ❑ Gravel ❑ Sandy Loam F] Clay Loam ❑ Clay ❑ Adobe LLJ-iardpan ❑ l 3 Previous Application Made: Yes ❑ No gg--Kew Construction: YesEQ�ko ❑ _ TYPE OF INSTALLATION 'AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Slank: Distance from nearest well----------------- Distance from foundation ----- .-------------- MateriaL_-___--.--_-_-__.-----._-_-__---.---..------- zNo. of compartments-------------- ----------- Size ------------------- -- ---------Liquid depth ---------------- ---------- Capacity ----=----------------- k D+ispo al Distance from nearest well __ _.Distance from foundation-. Distance to nearest to line --;E_- Length of each line______- -- VT idth of trench.____ ____--------------Number of lines_______._ ___ //Type of filter materia ---_- Repth of filter material__. ____ ___._____otal length_________(�.__(S _-.- ,Seepage Pit: Distance to nearest well ---------------___---Distance from foundation ------------------ Distance to nearest lot lin ❑ Number of pits ------i--------------- Lining material ----------------------- Size: Diameter --------••------------- Deptn---- - -----------------------_- Cesspool: Dis a "e from nea*est well __-_.----._____Distance from foundation.. ----------------- Lining material -------------------- .-----______..._-. ❑ Diameter -------- --------- ---- --- Depth --------------------------------- =---- - ----Liquid Capacity_----------------------= 9 Rrivy �: .=.t _ �–s 1� 3ta n �cfror nearest -well_._ -_ ---' _:=_-w.i?is#�nce:frornneares#building-- s -- Distanceto nearest lot line-- -------------------------------------------- --------------------- ------------------------- ------ I ------------------ ------------------- r , Remodeling and/or repairing (describe):-------------------------------------------------------------_--------------------- ------------------------------------------------- ----------------------------•--••--------------------------------------- ---------------------------- f -------------------------------------------------------------- - -------- -------------•---------%•'---•--------...-----•-- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County y ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. '""`- - -----------------------------------------------------(Owner and/or Contractor) (Signed) ---------------- ---------- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i ' FOR DEPARTMENT USE ONLY 4. APPLICATION ACCEPTED BY---------------------------------------------------------------------------------------- DATE = 3 " REVIEWED BY---------------------------------------------------------- ---------------------------------------------- -------------------- DATE------------------------ - lBUILDING PERMIT ISSUED._------------------------------------------------------------------------------- -- - DAT-------------------------------------------------------------- - -- . . _------------ mendatAlterations and/or recom5+ f -- -------------------------------------------------------- --------•---------------------------------------- f------ ---- + _ r c�------... - -- r - D 7-..i�-_ ��--------12aj - --------------------------------------------------- ----------------- -- - ---- - - -- FINAL INSPECTION BY:...r " �;•�-. �'"`L �7 Date ---- J 7 f SAN JOAQUIN L CAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, Californi a Manteca California T cy California J ES -4-2M 10-52 Revised W-2100 ? ;/ Q t--