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APPLICATION FOR SANITATION PERMIT Permi+ No. . ... _---------- (Complete in Duplicate) Date Issued __t O/ S3 plicati n is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance-with County Ordinance No. 549. J n JOB ADDRESS`AND LO TION------ - .----- ��-- -- ------ �- -- e ------- -- a,� Owner's Name--- ,� L'E? -- �7�riufJ� ---t��,��<ta- - - Phone---.1-,4._'��" Address---------------------------------- ------------------------------------------------------------------------- Contractor's Name------------ -_ ------ ------ Phone---- �-l - Instailafion will serve: Residence I. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ {Vumber of living units: __I-_ Number of bedrooms -_'ri~r Number of baths .-t___ Lot size ____________________ Water Supply:* Public system ❑ -Community system ❑ - Private;kl__Depth to Water Table _? ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam ❑ Clay ❑ Adobe Hardpan E] Previous Application Made: %Yes ❑ No ,. New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is'available within 200 feet.) ` Septic Tank: Distance from nearest well O_''.__Distance from f0jo dation_ _!�_ ___-_Materi l---_.�_-��. .` No. of compartments-_ ------Size,---A_5_ -.__.---Liquid depth__% w--------------Capacity-(?--&------.__._--. ' Disposal Field: Distance from nearest we ldp.--._-_._Distance from foundation__/,0_--- -------Distance to nearest lot line--- Number oil lines'-_1-------- it Length of each line- ------------.Width of french------------------------ Type of filter material__y---2 -----Depth of filter material____ -I-..........Total length_°_., ?---------------------------- I -- ------------_-..____.- Q0 r Seepage Pit: Distance to nearest well.. . _f_______Distance from foundation_�_a__-_--.___.D�stance to nearest lot line--3-�__. j Number of pits-11A _______________Lining material_CC_(�Y�' .__.Size: Diameter---�_�_�__- ---Depth___a.�_--___---.--------- I . L Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material------------------------------------- . ❑ Size. Diameter_-!-- ---------------------------------Depth--------- ------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------_-------------. 1 ❑ Distance to nearest lot line----- ------------------- ------------------------------------------------------------------- --•- --------------------------------------- Remodelingand/or repairing (describe):---------------------- ------------------------------------------------------------------------- -------------------------------------------------------- ------------•-•-------------------•--------------------------------------------------------------------------------------------------------------------------------------------------------.--------------------------------- ---------------------------------------------•-------------------------------------- ----------------------•-•----------------------------------------•-•--------------------------•----------------------------------------- --------- ---- -------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- Y ' I hereby erf fy-t f I h T14 prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, f laws, and s and regulations of the San Joaquin Local Health District. } (Signed}------- . • ----- C----------------------- ( �► Contractosl h s B ' ------------------------'...-----------:------------------------ �V--- {Title} �= Y• (Plot plan, showing size of lot, location of system in rel on to wells, buil ' gs, efc., can be placed on reverse side). t OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- DATE. '__/ �� REVIEWEDBY-------------------------------------------- ---- ---------------------------------------------------------- DATE------ ---------------------------------------------------- BUILDINGPERMIT ISSUED-------•_.-----_-------------------------------------------------------------------------------------- DATE----------------------------------------------------------- Alterationsand/or recommendations:------- ------------------ ------------------ -------•------------------------------------ -----------•-------------------------------------------------------- 1 ---------------------- ----------- -----------------•----------------•------------------------------------------------------------------•---------------------------------------------------------------------------------- -------------------------------------------------------- -=------------------------------------------ -- -----------••----------------------------- -----------------------------------------------------------•------------ r �4 -----------------------------•------------------------------------------- -- -- -------- ------------------------- 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 r E ES-4-2M �0-52,Revised W-2100 —AR