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APPLICATION FOR SANITATION PERMIT Permit No. 23-22--- " (Complete in Duplicate) _ "' 171 Date Issued _- -- -- �"-y 71 Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. r This application is made in 'complianc ith County grdinance No: 549. of JOB ADDRESS A LQ TIO LIPT y . , ` r� f I� ��__• -- -- lOwne � ---- - ----° --__ -•----- -------------------�_._ -- Phone--- 3_8`7 Address------LIC I «_ Contractor's Name = Phone Installation will serve: Residence Apartment House ❑ Commercial Trailer Court _ ❑ ❑ Motel ❑ Other ❑ Number of living units: __ [_ umber of bedrooms %3--- Number of baths -�-- Lot size -- - _��4�/ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel F] Sandy Loam E], Clay Loam E] Clay El Adobe ee Hardpan E] _ Previous Application Made: Yes ❑ No New Construction: Yes RooNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: a (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I s Septic ank: Distance from nearest well _"'+ __ Dist cfrom ound tion--- ---- rl ----------------------- ! j ------ No. of compartments-------------N----- -Sizer----A----- - Liquidff depth------ -------------Capacity-- - -Lel ---� Dispos I Field. -,,- Distance from nearest well--7_ _________.Distance from foundation____/ --------Distance to nearest lotjin�,,Z- F Number of lines---------- -- Length of each line------------------- t(""--.Width of trench----_"-"-- 14 r--- x. Type offilter materia �D -. -----"""-- -epth of #filter mater�al ---------Total length-------•-------- ---J'/--�--------j Seepage Pit: Distance"to nearest well---------------------- - __Disfiance from foundation___________________.Distance to nearest lot line____:__.._`- ❑ Number of pits-----:----------------Lining material-----------------------Size: Diameter-----------------------Depth-----------------------------1 Cesspool: Distance' from nearest well_________________Distance from foundation---------.--------- Lining material----------------------------------f ElSize: Diameter --------------------Depth----------------------------------------------------Liquid Capacity------------------ gal ' Privy: Distanco'from nearest well-------------------------------- ----------------Distance from nearest building ------------------------------- . .R ❑ Distance,fo nearest lot line_____________ ---------------------------- R odling nd/or repai�in Y(dcribe)------------------- �,• - -------------------------------------- 1 -- �.._ ---------------------------------•-------------------- -----------------------------------------------------------------------------------••-----------------------•--------------------------------------- - - ----- ----- -- --- - - -- ------------ ----- ---- - ------ - --------•- --- - ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S ate laws, and rules and r gulations of the San Joaquin Local Health District. (Signed) / !_ ------ -e -------------------------------------------------------------(Owner and/or Contractor) 4 By:----------------- ----------------------------------------------------------•----------------------------------- ------------- Title I (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ _________.------•"_-----_---" DATE--- ---------------------------------------------------------------- REVIEWED BY DATE BUILDING PERMIT ISSUED--------- ------------ DATE- - ------------------------------------------ -------------------------- ------------------------------- ------------ -------------------------------------- A Alterations and/or recommendations: .___________________________" -------------------------------------- _________________________________________________'--------------------------------------------------------- FINAL INSPECTION 8Y:___.. -'_V ------------------------------- Date---------- - -- ----------------- I� . SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California ES--9-21vl 5-51 Revised W-2140, .