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4 APPLICATION FOR SANITATION PERMIT Permit No.'"'�"" •_ : - 1 .I (Complete in Duplicate) . Date Issued ---�- h Applica-l-ionjs hereby_made,to the'San Joaquin-Local Health District for a permit to'Construct andtiinstall the work herein described. ; This application is made in compliance with-County'Ordinance No. 549. OB ADDRESS AND I OCATION . Owner's Nam --- ---"--------------------=--- --------------------------------- Phone ---; = ry -a. Address. .. ----------- = r�---r3 ------------ Phone----------------------------------- Contractor's Name------------------------- ` -------------------- ------ E Installation will serve: Residence Apartment House ❑ Commercial;E] T.railer Court ❑ Motel ❑ Other ❑ Number of livingunits: _; eNumber of bedrooms �___ Number of;baAs - Lot size .. f�'`�-------- Water Supply: Public system *Community system ❑ Private ❑ rDepth:to WafertTeble�ft. � Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam ❑ Clay Loam j]. Clay ❑ AdobeV Hardpan E] ,� i \ Previous Application Made: Yes ❑ Noj� New Construction:' Yes No El T TYPE OF•INSTALLATION AND SPECIFICATIONS: �J - .-A `(No septic tank or cesspool permitted if public sewer is available within 200 feet.) $ Tank- Distance from nearest well-_;__---.______Distance from foundation_________________-Material____________...______________"-- --------_""" No. of compartments------------------------- ------Liquid depth---------------- -- ---Capacity � _Size'------• ---------------- - - ---------------�--.. Dispos I Fiel Distance from nearest wells Distance from foundation�o-.r�-.---Distance to nearest lot line----, _____.. Number of lines----/-------------- --- ----- ;Length of each line--_. """"-- -`t-------Width of trench------� --•---------------- �` Type of filter material __Depth of filter material__. .........Total length_______.__ �----------------------- Seepage Pit: Distance to ,nearest well----------------_-----Distance from foundation_:______________.Distance to nearest lot line__'____.____.____ ❑ Number of pits Lining material---------- ------------Size: Diameter-----------------------Dept'n-------=------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------- material-- ._______:____-._________-_____ ❑ Size: Diameter------ ---------------- ------Depth------ -------------- ---------------------{---- Liquid Capacity-----------------------------gals. Privy: } Distance from nearest well------------------------------------- Distance from nearest bui mg_____. Distance to nearest lot line------------------- - -- :" ❑ ----------------- - Re odeling and/or repairing (describe):__--- - .. ---------•----------------------------- -------- ----------------- -------------------- ----------••---------------------•----------------•:---------------------------•-•----•--------------------------- I hereby certify that I have Or are this applic on and that the work will be done in accordance with San Joaquin County ordinances, State I nd r d regulations the San Joaquin Local Health District. x Owner and/or Contractor) I By (Signe _y. Title------ - ------------------ ---------------- - - --� (Plot phin, showing size of lot, location of system in relation to wells, buildings, etc., can be p ed o everse side). ;F FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-'"---------- ------ ---�- - --------- ---------------••----------- DATE -: ------------------ - ' -- ------- - - I a'" DATE121_1_ -1 --- - ------------------ BUILDING PERMIT ISSUED--------` ,/moi-""f----�- - DATE..-- -(----- r REVIEWED BY = Alterations and/or recommendations:-- --- -- ------------------------------------•----------------------------------•------ f ------------------------------------------------ - -------------------- ------------------------------------ 1 ----------•------__----------------- ---------- ----------=- ------------•-- ----- -- ------ ----- -----I------ r FINALINSPECTION 6Y:----- --- ----- - --------- Date------- -------------- --------------- ------------------------------------ SAN ------------------ ----------------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streetw300 Wasf Oak Sheet 132 Sycamore Street 814 North "C" Streef Stockton, California ~' Lodi, California Manteca, California Tracy, California ES-9-2M 145446 arw000 12-54 �I