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1�qI APPLICATION FOR SANITATION PERMIT Permit No. - a .0 (Complete in .Duplicate),,. Date Issued IT Applica�ion 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 County Ordinance No. 549. r JOB ADDRESS AND LO TION - = -------------------------------------- --------- 7�-- --------------- - ------------- - - ' Owner's Name------------ ------------------------------- - -------------- -- ----- ------------------------------------ --------------=--------------------- Phone----------------------------------- Address ----------------------------------- - ------------------------------------------------------------------------------...----------------------------------------------------------------........... ... Contractor's Name-----I------------- ----- `---- ------ Phone----....----•------------•------••- ----------------- _ Installation will serve: Residence partment House ❑ Commercial ❑ Trailer:Court ❑ Motel ❑ Other ❑ Number of living-units:_-__:_ Number-of bedrooms -�-_._ Number of baths -_- :_ Lot'size ------------- _} _l_ --------- Water Supply:' "Public system ❑ ""Community system ❑ Private ®-Dep to Water Table -------- ft. Character of soil to a'depfh of 3 feet: _Sand [] Gravel E] Sandy Loam H�_- yy oa m ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ )No [j_-New Construction: ! ' TYPE OF INSTALLATION AND SPECIFICATIONS: 1 ) } b -(No septic tank"or cesspool permitfed if public sewer is available within 200 feet.) I I Se tic Ta Disfance from nearest�well-----------------Distance from foundation_-- _ __--------Material-_-_-_-_� �A a - p - � r 4' }` q p- ----------- ------------------Capacity----------------- - No. of eom artments------ Size.-- --- .2t., �_-Li ui _ Disposal Field: Distance from nearest well .� �Uistancegfrom foundation ;:Distance to.nearest lot line-__-s _ � e if Type or filter matenaL _.�____ � _ .Length of each fine--- --: __ n_C?-:Width of trench----_-.._. -_-.---__-_-_-_ Number of Imes---'___----t---------------- -_-_ Depth of filter material--_- length--:--------- : t _ _ . t Seepage Pit: "" Distance to nearest well---_.-___.__`_-: =Distance from fou.ndation__ ___ _ Distance to nearest ]ot line--------.-------- V ❑ Number of pits---- ----------------Lining material-- --------- .Size: Diameter-----------------------Depth----------------------•---------- F Cesspool: Distance fi;om nearest well_________________Distance from foundation------------ J-:--,Lining material-------------------------------------- 171 -____--------.----.--.. -_---_-----.❑ er f----------------- -Depth-------------- ---------- :.:!--i ---Liquid Capacity ---------------------------gals. Priv . Distance ro s Size: Diamet i m nearest well - `-�D�stance fro nearest buildings ._-.-_--- -----__ -.---..-. ❑ -."...._.,:Distance to'nearest lot line - —4-1— --- - x -f ------------------------------_E.. -------- --- H. Remoa eling and/or refpairing (describe):---------------------- -___ -----,_. 1 I - E E 4 . . = --------- -------- ------- -- --------------------------- ------------------------------------------.-----------------`------------------------------------------------------ ---------------------•----------. -------- y hhereby certify.fhat-1 have prepared this application and•that the work will be done in-accordance with San Joaquin County ordinances, State laws,' and,rules and regulations of the'San Joaquin Local Health District. [Signed)_...... . . -:.�----�---J� '1 --------------------_ -------------------(Owner and/or Contractor) By:----------------------------------------- `= = [Title) -----------------------------------` - (Plot plan, showing size of lot, location of system in relation to wells,'buildings, etc., can be placed on reverse4side)i {. i3 FOR-DEPARTMENT USE ONLY APPLICATION ACCEPTED';BY--------------=----------- - t -------------------------------- DATE------------------I-----------.-S %- REVIEWEDBY------------- ------------------.----- --- ------------------=--=-------=-=-------------- =---- ------ DATE------------------------------- BUILDINGPERMIT ISSUED:__.-.-----------------------------------------------------------------..--...----------------------- DATE-------------------•=------------------ - Alterations and/or,recommendations:_,__'--------------------------------- ------------------------ ---------------------------- -•-•----------•------------ .... --------------------------------------------- ---- -------- -------------------------=------------------------- ---------------------------------------------------------------------------......--------------------------------------- I - k1 - ------------- --- --------------- --------------------- HNAL -------- IN BY:-'-; Date-------- = ----------------------------------------------------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Strevi Stockton, California Lodi, California Manteca, California Tracy, California 4 - t ES-4-2M Revised W-2100