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p.. APPLICATION FOR SANITATION PERMIT Permit No. f....... (Complete in Duplicate) 3� Date Issued 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, JOB ADDRESS AND LOCATION!-= ---------------4.�-1If�R- ------ ---- ---U�-------------------------------------------------------------- Owner's Name----- --= ------=I` ... _r2 Phone -- - -- Address............. --•- ----------- -------------• f Contractor's Name----------- - -------------------------------•------------------- Phone-�'i a ��PQ� Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other-E] Number of living units: __1____1'N umber-of bedrooms . - Number of baths __ ._._ Lot size __Zdtv------_ � Water Supply: Public system Iimmunity system ❑ Private ❑ Depth to Water Table—:5is ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay 0--Aciobe E] Hardpan E] Previous Application Made: Yes ❑ No New Construction. Yes No 14_� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: No. of co m r earesf well ______________Distance from foundation_-__.______._.____-Material________.___._____.____..___-.___._____.._____- El ems--------- ------- -- ----Size--------------------- ---------Liquid depth---------------- ----- ---Capacity Disposal Fi d: 'Dist c from nearest well.................Distance from foundation--------------------Distance to nearest lot line._____.__..______-- ❑ um er ines------------- ---------------Length of each line------------------------------Width of trench---------------------- --- -----•-- Type of filter riiaterial-________________________Depth of filter material-----------------,.,----Total length___.___-_______-_______________________- r Seepage Pit: Distance to nearest well......'V.d7_t Qistance from foundati n____ -_---------Distance to nearest lot line___-e�O--_r__ Number of pits.. ..__./------------Lining material ie�Diameter--.__,`';_:t;"..Depth- - -________._ ;I Cesspool: Distance from:,nearest well________________Distance from foundation----------------____Lining material------------------------------------- ❑ Size: Diameter-------- -----------------------------Depth.-------------------------------------- `-----.-----Liquid Capacity----------------------------gals. -� Privy: Distance from lrearest well-----------------------------.-------.----------...Distance from nearest building_._._________.________.....___-.---____._. ❑ Distance to nearest lot line------------------ - --------------------------------------------------------------------------------------------------------------------- iih Remodelingand/or repairing (deJlribe):--------- ------------------- ---- --------------------------------------------------------------------•------•-----••----------------------------•---- I� -----------------•--•-----:i ----------------- � - ----•-------- -----------------•-------------------------------------------•-•--•-----•-------•--------------------------------------•------------------------------- -------- �I I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, uand regulations of the San Joaquin Local Health District. Stat aws, nd rules ee' - _ - { 1/ - - {Owner and/or Contractor) Si ne By: =--� -- •---•--------(Title)---- --- -------------p---------------: . --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). �I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------ ---------- ----------------------•---;------------------------------ DATEg-._"_'-- --------------- --------------------------------- REVIEWED BY------------------------------ _.. ----._ DATE___��_. ----- - --------------------------- BUILDINGPERMIT ISSUED------------- -------------------------------------------------------------------------------- DATE-----&6-------------------------------------------------- Alterations and/or recommendations: . -------------------------------------------------------------- - --=--- V ----;I---- ---- ------ ---------------------------- - ------ ------------•---------•--------..---•--•-------••--- --- ---------------------- - -- - ---- -------=�1=-----------=------------------------------- -- -------- ---------------------------------------------------------- - --------------------------------------------------------------------------- ; C, FINAL INSPECTION BY:-------- ---- - -_ - -------------------- Date------------- ------------------ 3-- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street I 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M I459Afi AT W DO ^12-59 04