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�7 c� r APPLICATION FOR SANITATION PERMIT Permit No. _ -_---_-__-_ I 6 4 (Complete in Duplicate} Date Issued �__-�-_`�__--- -�- 3 : 1 t Application is he eby m'a'de 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 Cou.nty Ordinance No. 549. V�I 'I -- JOB ADDRESS AND LOCATION -� '� ---------------------- - ---- ---- ---- !t 1( Owner's Name #€�/ Phone -------------------------------------- Address--------------------- Q---J------ ---- Contractor's Name___-____ Q_f Q."___ -- _- _ -------- ---------- f -J------- Phone---_ 4-----�-------- Installation will serve: Residence ❑ Apartment House ❑ Commercial �I Trailer Court ❑ Motel ❑ Other Number of living units: --.----- Number of bedrooms -------- Number of baa s -- ----- Lot size ----- --- Water Supply: Public system ❑ Community system ❑ Private epth to Water Table __ 4 Character of soil to a depth of 3 feet: Sand ravel L oam❑ Sandy Loay Loam El lay E] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed if public sewer is available within 200 feet.) , �III Septic Tank: Distance from nearest well-----------------Distance, from foundation_____________-_____.Material_________________________--__________________.. ❑ No. of compartments--------------------------Size-.-.------------- -1 -----Liquid depth---------- ---------------Capacity-----------/--- ------ Disposal F' d: Distance from near t well------------------- from fou.dati X Distance to nearest to Ike__---_�_____- Len th of each line___ __ Width of trench__ t� Number of lines g Q Type of filter material_5�_ _-Depth of filter material__ _ ._-___-____Total length____ __________ // Seepage Distance to nearest well_____________________Distance f MRfou ation_�__0,____--Distance to nearest lot line----16--_____ of pits-_ J-------_Lining material_ is.. Diameter______, -- -----Dept h----- G ---------------- Number r Y�i I Cesspool: Distance from nearest well--------------:__Distance from foundation___________________Lining material----------------._-_:__________-____ ❑ Size: Diameter--------- ---------------------------Depth---------------------I----------------------:- Liquid Capacity T - gals. .. - _ � � u d_cepa - i Privy: Distance from nearest well------------------------------------------------:.Distance from nearest building---------------------------.-----_.------ ❑ Distance to nearest lot line--------------------- ----------------- --- ------------------------------------------- Remodeling and/or repairing (describe)------------------- - -------- ---- -------I- ---------------------- ------------------------------------------------------------------------------------ ---------- ------------------------------------------------------------------------------------- ;il111 ------------------------------------------- '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 an regulations of the Sa Joaquin Local H alth District. I � _ A Own and/or ntracto (Signed) g ----- -- -- -------- --------------------T1tle (Plot plan, showing size of lot, location-of system in relation to wells, buildings, etc., can be placed on reverse side). dt FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_-- - DATE- -�--------------------------------------------------- REVIEWED BY------------------------------------ I� DATE ---- -- ---------------------------------- -------------------------------------- BUILDING PERMIT ISSUED--------------- N DATE------------\,--------------------------------------------- Alterations and/dr recommendations----------- ------------------------------------------------- I--------------------- --------------- --•------------------------------------------ ------------------------------------------------------------------------------------- - --------------------------------------------=-------------------------------------------------------------------- ------------------------- ------ ----•-- - ----------------------- ------------- ---------------------------------------------------.----------------- -- ------------------- --------------------------------------------------------- I i �; ----------------------------------------------- - ------------------------------- FINAL INSPECTION BY----------------- ------------ 11 Dater- ------- -- ------------------------ -------•-==----------- SAN JOAQUIN LOCAL HEALI.TH DISTRICT 130 South American Street 300 West Oak Street 11 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 6-51 Revised W-2100