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APPLICATION FOR SANITATION PERMIT Permit No. ..-_.1{-7. . (Complete in Duplicate) ]� W.- —A ► Date Issued Application 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 complianc'e with County Ordinance No. 549. . JOB ADDRESS AND LO *Z, TION___ ' ' - S / Owner's Name ----------------------- ---------------- Phone Address-------------------- ---------------- --- ---- ---------------------------------------------------------------------------------------------------I------------------------------------------- Contractor's Name-------------------------------------------------- ------------------------------------------------------------------------------------------- Phone Installation will serve: Residence ff] Apartment House E] Commercial Trailer Court E] Motel El Other ❑ Number of living units, N'Umber of bedrooms _3--- Number of baths _/---- Lot Wafer Supply: Public system ❑ Community system E] Private 4 Depth to Wafer Table .-----_. ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [K Clay Loam 0 Clay ❑ Adobe E] Hardpan ❑ Previous Application Made: Yes E] JNo El Now Construction: Yes El No Ej TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool peirniffed if public sewer is available within 200 feet.) Septic Tank: J-DIsf v Icompartments--------------------------Size--.-__-----_ from nearest,� rest well-----------------Distance from foundation--------------------Materiai ---------- -----.---------------- -- * El of compartments ----Size-------------------------------Liquid depth----_ ------- -----------Capacity------------- -------- Disposal Field: Distance from nearest well-5-0....IL—Distance from foundafion_A_5___'.e Distance to nearesilof line- S_ Number of lines---_-----Z---------------------Length of each Type of fil�er material-------------------_----Depth Width of trench.- XA---------------------- Seepage Pit: Distance to nearest well-------- of filter material------ --------Total length-------�ii,6-------------------------- El Number of pits------- --------------Distance from foundation_-______-----_----.Distance to nearest lof line_------.------__ ---------------Lining material-----------------------Size: Diarnefer---------- ------------Depth--------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------- El Size: Diameter--------------------------------------Depth----------------------- ------------------ -----------------------------Liquid Capacity_----------------- -------.gals. a I Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------- --------------------- El rDistance_to nppr�esfjofjine----------------------------------------------a I — ------------------------------------------- Remodeling and/or repairing (describe]:.- _-_ -- ---- -- &-a—V----- ��---------e W_ ---------------------------- ----------------------------------- ------------------- ----------------------------1------------ -------------- ------------------ ----------------------------------------------------------------------------------------------------------------I--------------------------------------------------------- ----------------------------------------- ------------------------- ---------- ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- I hereby certify that I 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)__- '_---OVI-111 - ---------------- -------------7--------------- --------- ---------------------------------------------------------------------------(Owner and/or Contractor) By:__---- ------- ------------------------------ ----- - Title I - - (Plot plan, showing size of lot, location of system in relation to Wells, buildings, etc., can be placed on reverse side). FO EPART ENT U ONLY APPLICATION ACCEPTED BY--_. --- ----i---- ----------- ------------------ - - -- --- ------------------ DATE------BY _/ -_ - - - -- ------------------ BUILDING PERMIT ----------------- ---------------------------------------- DATE------------------------------------------------------------ Alterations and/or recommendations:-.,--I---------------------- ------- --------------------------------------------- DATE------------------------------------------------------------- -------------------------I------Y�7------------* ----------------------------------- ------- ---------------------------------------- ----------- -- ----- t_7 0 Y-4 0' -------------------------------x----------------------------------------------------------------------------------------------- -------------------------------------------------- ---------------- ----------------------------------------------------------------------------------------------------------------------:......------------------------ ----------------------------------- ...... ---------------------11 ---------------------- --------------------------------------- -------------- --------------------------------------------- --------------------- ------ /005�9 FINAL INSPECTION BY:-----------1V,4,q_ ------------------------- Date----- --- _/-0--—;,/S- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-11-2M 10-52 Revised W-2100