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APPLICATION FOR SANITATION PERMIT Permit No.,;�73l..6. ; y (Complete in Duplicate) Date Issued 4_77//7;S4 I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. f This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION- -- ��- ----------------- ---------------------- /,� --� --•--•----------------------------•--- ----------------------------- Owner's Name------ ! --t-/ {=f l� •---------------- -- ----- ---- Pion ----------- Address------------- - -�0.... ----------------- --------------------------- Contractor's Name---------------- ----- ------------------------- Phone------------ ------ Ins+aIle+ion will serve: Residence Apartment use ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms ._��lumber of baths ------[_ Lot size Water Supply: Public system ❑ Community system ❑ 'Private N Depth to Water Character of soil to a depth of 3 feet: Sand E] Gravel ❑ -Sandy Loam E] Clay Loam F] Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ❑ No P5 New Construction: Yes ❑ NoX TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__01001 Distance from fours)9tion----!__-__.--Materi ____J d_L__' C�_-�. -----. No. of compartments__---___�---__Size___3_X-_--_x__---.___Liquid depth-----------��_--------Capacity_____g_��___ Disposal Field: Distance from nearest eI1_9&�.�Distance from foundatiog____,. ___._.Distance to nearest I t line_ ------ Number of lines___..________________ __ __Length of each line_______ Width of trench_.___- �____________________ Type of filter material.,�4Depth of filter material____-_ _-_.__-___Total length------------T"" ---------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ . Number of pits----------------------Lining material-------------------.--.Size: Diameteir_----------:----- ----Depth--------- Distance from nearest well-----------_-----Distance from foundation--------------------Lining material-_-__.-_.__________._____-.-_-_-_--_. ❑ Size: Diameter--------------------------------------Depth----------------------------- ----------------------Liquid Capacity----------------------------gals. � Privy: Distance from nearest well----._____;------------------------------------__Distance from nearest building-----...-__-----_-_-__--____________-_.__ ❑ Distance to nearest lot 4 line----------------------- -------------------------•--------- ------------------------------------------------------------- r repairs g Idescribe):-Rem elfin9 nd/o1-- -- --- b • ---------------- F� 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. (S*Lgned)_____�----5�_ : _-- -._ -- ------------------------------------(Owner and/or Contractor) (Plot plan, showing size of lot, locationtrof system in relation to wells, buildings, etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------`-------------------- - ----- -- ----------------------------------------------- DATE-------------------- REVIEWEDBY -------------------------------------------------------- DATE----------- --r-:��--------------------------- BUILDING PERMIT ISSUED----------------------------- -- ---------------------------------------------------------------- DATE------------�---- ------------------------ Alterations and/or recommendations:_____---__.-_ ------------------------------------------------------------- ° -------------------------------•-------------------------------------------------------------------- ---------------------------- ---------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- ------- -------- -------- --- FINAL INSPECTION BY------ ----------- -----------------------------•---------- . Date------07 ------ ._ . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California I E5-9-2M 0-52 Revised W-2100