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APPLICATION FOR SANITATION PERMIT Permit No. .= � -• / (Complete in Duplicate) Date Issued J Thislappl cationication i's eis madeanc ompl ince with o the San pCountyuin a0 dine ceeh DlNo. 549.strict for a permit to construct and install the work herein described, I JOB ADDRESS AND LOCATION_______________° � 1 `� �'-e4-S T IN ► ( 2 S -- -------------------------------- ------------------------------------------------------------- Owner's Name.-----•---•----•------•-------•--��---�®�,-- l� .Address 4-1 , ----------------- ," - ------------------------ Phone 9- 7 ---•----------------•--------- Contracfior's Name ------------- ---•-------- - ----------------------------- -----------•-------------------- Phone Installation will serve: Residence D4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ F Number of living units: _______ Number of bedrooms __ -- Number of baths J____ Lot size Water Supply: Public system C4 Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ElGravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe N Hardpan ❑ Previous Application Made: Yes Q, No IR New Construction: Yes ® 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 well_-__`"_-- -----Distance from foundation----10t--------Material-________ yam/ No. of compartments--------------—- " Size ----Liquid depth----- Y'-U _._.Capacity------ er --Disp l Field: Distance from nearest well__.-- - -.Distance from foundation-----!�4?--- -----Distance to nearest lot line-______S�- Number of lines--------- ---« - - --Length of each line------------------------------Width of trench----------.-,2—�� Type of filter material-_ ._ ._ � t ______ _ " epth of filter material y___..Total "length--__._____-. /' .D N ------ --------------- -------- r� Seepage Pit: Distance to nearest well_.___________ Distance from foundation_______--___._.__..Distance to nearest lot line__._______-----_ v' ❑ Number of pits----------------------Lining material-----------------------Size: Diameter----------------- -----Depth----------------------- Cesspool: -------- D}sfance from nearest well------------_._ Distance from foundatiori--------------------Lining material__________----._________----_-----_ ❑ Size: Diameter------ Depth --------------------------------------------- ------Uqui.d Capacity ------- ------ ---gals. Privy: Distance from nearest well-------+----------------------------------------- g Distance from nearest building F ❑ Distance to nearest lot Remodeling and/or repairing (describe):-------------------- ---------------------- ---------------------•-------------•-------------•-------------------------------- -----•------••-----•---------------- ---------------------•-----------------------------------.----- I hereby certify that 1.have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S fe laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---- By: i ned BY= - ---------------------------------------------(O- wner and/or Co ntractor) C! - ------ --------------------- -Title------------------------------------------ _at plan, showing size of lot, location of system,in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__________________ _ _ DATE______.____.-_ REVIEWED BYt -------- - DATE -- ----------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ --------- DATE---- ---------------------- -- - -------------------------------------------- Alterations and/or recommendations------- --------------------------------------------------------------------------------------------- _________________._---_•-__ -__ ----------------------------- ---------------------•-----------------------•--------------- ---------------------------•------- -- --------------------------------------- -------------------------------------------I-------------- FINAL -- - ------------- FINAL INSPECTION BY:.. j Date �. .-_ / -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9----2M 10-52 Revised W-2100