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ell APPLICATION FOR SANITATION PERMIT Permit No. ___ - �.....--. (Complete in Duplicate) Date Issued ------ A . 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 compliance with County Ordinance No. 549. JOBADDRESS AND LOCATION-----------.�'f�-'--- -------� --------- -------------------------------- ---- - - ---------------------•-----•--.-----------------------------------••-- Owner's Phone Address.-----------/-4&./ Q------- --------------------------------------------------------------------------------------------------- ------------------ :-----------------------Name �- �' - Phone_ ------------- = Installation will-serve: Residence pf,_Apartmenf House ❑ Commercial ❑ Trailer Court ❑ Motel ❑y Other Number of living units: I______ Number of bedrooms _ _ Number of baths __/___ Lot size --- ____/Sr..L ----------------- Water Supply: Public system JZ—.Community system ❑ Private ❑ Depth to Water Table &I ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E] Previous Application Made: Yes ❑ No 5L New Construction: Yes QU_No ❑ A TYPE OF INSTALLATION AND SPECIFICATIONS: f (No septic tank or cesspool permitted if public sewer is available within 200 feet.} , Septic Tank: Distance from nearest well__._/V&r3kDisfance from - foundation--- _ __________.Material---- _ _____.___-_ No. of compartments.... 4_Q-_------ Ca acit .--.---- - Y ! . Disposal Field: Distance from nearest well_,/e/,0,,&s_Disfance from foundation__ ,Z_q_......Distance to nearest lot line----14�J__. _Length of each line___-__- -� f. - .Width of trench_-_-__ .�------------------- Number of lines........ .-.�;-. ------- g Type of filter material-____ `�___ _ Depth of filter material_________- -------- length_____... � -___________________ ol Seepage Pit: Distance to nearest well----e 8� Distance m. oun on___�_.'___..Distance to nearest lot line_________ Number of pits-------/------------Lining maferi -- --- - -- -- ------ Diameter._--. - - ------Deptn__c -4 __�--- ------ 1 , Cesspool: Distance from nearest well ________________Disfance from I odation...-__----------------Lining material_-___-_-_.-___-__________-__-_____. ❑ Size: ----------------Depth---- ------Liquid Capacity----------------------------gals. r Privy: Distance from nearest well--------------`------------------;---------=--.-Distance from nearest building-----.-----------------------------------. Distance to nearest lot line--------- ------------- Remodeling and/or repairing (describe)----------------------- --------•-----`- ------------------------------------------- ------------- •- --------------•----------------------••---------------------•-------------------------'-•-----`---------I----------------------------------------------------------- ------------ ---------------------------------------------------------•-------------»..----•----------------'--------------------------------------•--------------...-----A---------------------------- I i --------------_........-------------------------------------------- ------------------------------------ ------ -----------------------------••----------•-------•------------•---------------------------------_...---------• I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, and rules :and regulations of the San Joaquin Local Health District. Si nedY. —�- (Owner and/or Contractor) -._ �f Title r (Plot plan, shovring 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 REVIEWEDBY--------•--------------------- =------------ ---- ----- _ DATE----------- ^--•-------..._..--•---------•-•-------- BUILDINGPERMIT ISSUED-------------------------------- --- --------------------------------------------------------- DATE----- K-- Alterations and/or recommendations------- ------------- �: - U ------------------------------------------ ------------ -------- ----- ---------------•----------•------------------••------ --- -\�---..._..-------------•---- -------------------- % ------------------------------------------.---------------------------------.-----------------------------------•-- ,� � - 1� �, '-y>•-cs ---------------------------------------------------------------------•----... ----------------------- ---------------- ' FINALINSPECTION BY::------- C/ 5------------------------------- Date-----`-----------------I-----------=1----------------------------------------- 1 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21.9 145446 ATWOOO 12-54