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4 APPLICATION FOR SANITATION PERMIT 3 Permit No _____________________ a �J (Complete in Duplicate) Q/y • Date Issued A lica--ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. f?P Y q This application is made in compliance with County /Ordinance No. 549. JOB ADDRESS AND OCATION.. ,tC -= ------------------------- , . ? ------------------------- ------ ---------- --- - Phone Owner's Name__________ _ _ ______ . ------• --------- � �'`5 = ° r -------------------------- Address______ ____ / Contractor's Name--------_----------- -� PhonelP�_S�1i�6 Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/_._ Number of bedrooms 3_ Number of baths __/_ Lot size `fd_ __�_ _-_________________ Water Supply: Public system El system Private ❑ Depth to Water Table 7_�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe,X Hardpan ❑ Previous Application Made: Yes ❑ No f� New Construction: Yes No ❑ ' ` , TYPE OF INSTALLATION AND SPECIFICATIONS: ; (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �j Septic T Distance from nearest well��'e•�_-Distance from foundation---/D_-___--Mat riai_�L.______________ _ .____ 2) ______. _ C.. EEK No. of compartments- __- _.____Size-S+ _____��-------Liquid de th_.__ /_ Capacity— a aci -'-s�d Disposal Id: Distance from nearest well -----_---..._Distance from foundation---. __ _...Distance to nearest lot line_______-__.___ 9110 Number of lines------- -.-.---- S _ P� Length of each line_____� __-_-_____._.Width of trench_____ ___ .. -------------------- Type of filter material.st . . ____ __ Depth of filter material_-__-- ------Total length____________________"�s1_________ a Seepage Distance to nearest well_ _! _ ....__Distance from foundation...._______________.Distance to nearest lot line._- -:4 p' �----------Lining materia !..... P Number of its....__ ._ f� $ize: Diameter----�s�_--- -_--De th_____- ------------------ Cesspool: Distance from nearest well-----------------Distance from foundation___---------------- Lining material------------------------.------------ . 171 Size: Diameter----------------- - ------------------Depth-------------- ------------------------------ -----Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building--------------------.--------------------. ❑ Distance to nearest lot line----------------------- ------------------------------------------------------------------ ---------------------------------------------------- Remodeling and/or repairing (describe):---•--------------------------------------------------------...----------------------------•-------•-•-----------------------•-------------------•---- ------------------------------------- --------------•----------------------------------------------------•••--------------------------------•-----------------••---•-------------•------•-•-----------------------------•-•.----------------------------------- -------•---- --------•-----------------••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 regulation's of the San Joaquin Local Health District. (Signed) - f A,-----------------------------------------_ - (Owner and/or Contractor) BY: - moi, _ r� = f (Ti+le- -- (Plot plan, showing size of lot, location of systgr. In relation to wells, buildings, etc., can be placed on reverse side). 1 I: f1 FOR DEPARTMENT USE ONLY DATE APPLICATION ACCEPTED BY.....__--- ; REVIEWEDBY--------------------------------------------- ----------------------------1�." DATE --- ----•---------------• -•---- BUILDINGPERMIT ISSUED------------------------------------------------------------------- ---------------------------------- DATE------ ------------:----------------------------;-------- Alterations and/or:recommendations: -- ---- --- --------•-•------------------------------ --------- •------•- -----------......----------------------------- --------------- ----------- - -------- t -------------- -------------------------•--•-•---••---------- ----------- -- ----------------------------- --- FINAL INSPECTION BY:------ ---------------- ------------ Date-------- --------- ---------------------- ----- 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 x' Tracy, California ES-9-2M 145446 ATWDOO 12-54