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APPLICATION ATI ► � C ON FOR SANITATION PERMIT Permit No. ..`?__________________ t ! (Complete in Duplicate) 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. I� e JOB ADDRESS AND LOCATION LOC•.A- TION--- ----------- I' -- -m��----------_------•-----.-..----- Q___..-Owner's / ------- � --- .-. --------- --- Phone---• --------------...------------- Address------. Contractor's Name ........ _ _---- ------------------------------------- Installation will serve: Residence LkApartment House [-] Commercial ]] Trailer Court E] Motel ❑ Other ElNumber of living unifs: _ --- Number of bedrooms -._'_'lumber of baths __el- Lot size ------ An) _ ----•--------•-- Water Supply: Public system ®- Community system ❑ Private E] Depth to Water TableZT5 ft. Character of soil to a dep+! of 3 feet: Sand El Gravel ❑ Sandy Loam El Clay Loam ❑ Clay ❑ Adobe 0:� Hardpan ❑ Previous Application Made:i! Yes ❑ No PL New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: P ./0 , (No septic tank or cesspool permitted if public sewer is available within 200 feet.] Septic Tank: � Distance from nearest welL;��x.�,..Distance from foundation____.._ .__._,Material_. {� No. of compartments- ----------------Size----..5_____•-- Liquid depth---.- _0---------._Capacity------Q ------ Disposal Field: Distance from nearest well-___------_------Distance from foundation-------------..-.-_Distance to nearest lot line.-------____..__. ❑ Number of lines-------------------------------- --Length of each line---------------.--------------Width of trench----------------------------------- 'filter material-__---------------------Depth of filter material --..__--------------Total length----------------------- Type of ,i'! e � mac.... Seepage Pit: Distance to nearest well-../�/Q7%4,.Distance from foungla+ion--_-_&. ..... Distance to nearest lot line_-_-_�-.__-.___.- 1` , _ Number',of pits:---------�----------Lining material----__--�-'_ .�'f.��-3�`�: Diameter--------_'-,r----.-Depth-------�;.��._..'�.-------- i Cesspool: 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 line.-------------------------------- - - ----------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):----- ---------------------------- --------••------------------•---------------- ----------------------------•------------ II---••---------•------•-----------------------•----•----------------.....---------------••-------------•---•--------••-----------------••-------•---•--------•---------------- ----- -.-•---------- ---------------------------•--------•-----...._..._--...----------------------------------------------------------•----------•-•----------------•---------- ----••---------------------------------- ------------------ --- ------ --- -----------II--------------•--------------••-------•-------•------------------------------------•---------------- -------- ---- ------ ----------------- -----•-------------------------- I hereby certify that i have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S e aws, and'rules and regulations of the San Joaquin Local Health District. r I ' ----------------------(Signed) / °/ ^ (Owner and/or Contractor) t By:---- 7��a- .- _ l �fr� �---------------------------(Ti+le)---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r .�� FOR DEPARTMENT USE ONLY REVIEWED BY_APPLICATION ACCEPTED �BY--------- �'1� - --------------- DATE-----ti.------------- ----------------------- y 'I Y ----------- ----- --------------- ------- ------------------------------------- DATE. BUILDING PERMIT ISSUED- -------- -------------- i --�------------•-------------------------------------._ DATE----- --- --- - Alterations and/or recommendations----------------- ------ -------------------------------------------- ------------ _--------q . 1---------- ----------- -- _ S ':: c :::::::::::: ::::: ------------------- ------------ ------------ ---------- ------ ---------------------------- -----------------------1--------------- ----------------------------------------.......... ------------------------------------ - 4I .----------f----- -------------------.------------------- Date...FINAL INSPECTION 'BY:.1------------------------SAN _ . b ------------------ JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street ii 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California l Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWODD 32-541