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APPLICATION FOR SANITATION PERMIT Permit No. .....�1__-- !_--- (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 workherein scribed. This application is made in compliance iwith County Ordinance No. 549. Ni JOB ADDRESS AND OCP,�ION-. --: .:__ P Q✓ w ------------------------------------------------------- hone Owner s Name - - -- Address--------- Contractor's Name_________________ __ ___ p_ - A-Ar----V --------------------------------- � : Motei Other ❑ Installation will serve: Residence D :A'Apartment House ❑ Commercial ❑ Trailer Court ❑ ❑ _ Number of baths ------•------------------------------- Number of living units: _ :-- Number of bedrooms __ Lot size ---------------------- Water Supply: Public systarri 171 Cammuriity system ❑ Private.' Depth to Water Table 3U ft. Character of soil to a depth of 3 felt: Sand El Gravel ❑ Sandy Loam ❑ Clay Loam El Clay ❑ Adobex Hardpan ❑ Previous Application Made: Yews ❑- No New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: I [No septic tank'or cesspool pe�mitted if public sewer is available within 200 feet.) .. - I .SSE . Septic Tan Distance from nearest well_________________Distance from foundation___1�--'__ Notarial :- _________ o -:__Size56_Y_ �_- �?� Liquid depth yyv' --------------Capacityf� L7 No. of compartments__________ __ _ i Disposal Field: Distance from nearest well.. -- }_Distance from foundation_._`------ ----Distance to nearest lot line______.. p®� Nuir�ber of lines--- ----`- Length of each line_/��__^_._ ._.Width of trench---ti. ��----- f Type of:fiiter material-__L��' Depth of filter matefial___,f ----------Total length- S--Q--------- = .� Seepage-Pit: Distance to nearest.weli-------------------- Distance from foundation_______.____.-__.__.Distance to nearest of me_______.___.____. ' = Depth ❑ Number*of pits------------,-_------Lining material------------- c'--- Size,Dia�metier------------------- - -' Disterice from nearest well----------------- - _-_________ __ Distance from foundation_--___----_1-:_.__Lining material____-______________________--__.-__ Cesspool: i ` ' ___Li Liquid Capacity ---------------------gals. f q p : Y ❑ Size: Diameter------------------------- �.Depth_y_.----------- ' - `"""""------Distance from nearest building---------------------------------------- Privy: from nearest well----------- ------------------------------- : E Privy: a ❑ p "Distance"to nearest lot line:.`---` ------------------------------- -} Rem sling and/or re;airing descr-b ]_________ _________ ___ T -------•-- ---------------------------------••- r�it ` ` f i_. w .� �'' -:. p ------=------------------------------------------------- ----------,. ------- ----------------- --------------•----------------- -------- i f I hereb -certify that I hav6 Rp spared this application and that-the work will be done .in accordance with San Joaquin County ordinances, S afe laws; and rul� and regulations 6f the-San Joaquin Local Health District. �•� F r and/or Contract Hzlz ` __{Ownsor) --------- -- (Signed) _ T ---------•--------- ------- By: �' ------------------------------------------------------(Title)-------.---- - -------- By:---•----------------''s----"�'- `` ----- Plot plan, showing size of lot;location of-system in rtion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------- ------------------- ---------=------------------------------------ DATR = ` �� - `' !------- - ------ ---------- ------ DATE_.---�-------p°---�-------------�- REVIEWED BY -------------------- --- _ - --- --------=---------------------••-- DATE-------�--; •w =--------------------- - BUILD�NG PERMIT ISSUED '` A----------------------- ------------------------ Alter: fions and/or recommendations•---- ____ _______ -- --_- - -----_-- -"- -• rr 1 -- = ------------------- 'i r t -- - _ 1! ----------V, --- ----- ---- •------- r ' r ____________________ _ FINAL INSPECTION BY �------ ---------- Date:: __T.. __,�--=w=-=--- ==--------------- ' :.- � - SAN JOAQUIN LOCAL HEALTH DISTRICT : 132 Sycamore Street 814 North "C" Street ' 130 South American Street '300 Wast eek Street y Stockton, California Lodi, California Manteca, California Tracy, California ee a�9AA : Revised W-2100