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+, APPLICATION FOR SANITATION PERMIT �I�'� Permit No. r 4/-6-5(Complete in Duplicate) �' �-,�13r --ter %,�l Date issued J� _-._ Cl Application 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. 549,1 ti e 106 ADDRESS AND LOCATION... t �� r--- -- a ItO ` f---- ' - ------------ f" =` Phone-------------------------- --••----Owner's Name------------------- . :..Address-.--------------•---------------------_----- _ -------- --- Contractor's Name------------------------------------------------- ---------------------!---------------------------------- ----- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ OtheL..0 Number of living units: J____ Number of bedrooms __ - Number of baths __/___ Lot size ________________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ®'"Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No NrlNew Construction: Yes No ❑ 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___�e______Distance from fou�aption__149___-------Materai---cr--K:Crig� No. of compartments_________'j '"___._.__.Size___ Liquid depth ,_t__L____-------------Capacity----- ___ .. ------ Disposal - -Disposal Field: Distance from nearest well--- -0------Distance from foundation__/&4_ - Mance to nearest lot i`e____J___-_ 't- Nmber of lines_____ Length of each -I-- idth of trenchJ ___+_ `- Type of filter material-_- Depth of filter material____/9*--------Total length_______p-0-__ - ______________-___-_ Seepage Pit: Distance to nearest well------------------- Distance from foundation-------_-----------.Distance to nearest lot line_____________-__ ❑ Number of pits----------------------Lining material----"------------------Size: Diameter------------------------Dept h_.__----------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-----------.------- Lining material______-_--_-____________________-____. • 0 Size: Diameter--------------------------------------Depth--------------------------------------------------.-Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building _____________.__. --- --------------------------------- ❑ Distance to nearest lot line---------------------------------------- - --- --------------------------------------- -------- ' Remodelingand/or repairing (describe):---------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------- --------------- ----------------------------------•------•-----•-------------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------------ v --------------------—---------- --------------- ---------p------------------PP---------------------•----------------------------------------•----------------------------------------------------------------- y I herebycertifythat I have prepared this a lic ion and 'af the work will be done in accordance with San Joa uin Countordinances, State laws, and rul and' regulations tithe Sa Join Local Hea th District. # (Signed) "� " ------------ -- - - --- ---- --------------------(Owner and/or Contractor) By:-- -----------------------------------------------------------------------(Title)--------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DIiP�. TME tT USE 2LNLY APPLICATION ACCEPTED BY______ __ _______ / p cA�f - -- DATE fr- ' REVIEWEDBY------------------------------------------------------- -------------------------------------------- --------- DATE --------------------------- BUILDINGPERMIT ISSUED----------•------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterations and/or recommendations:------------------------------------------------------..------------------------------------- •--------------•-------.---------------------•--._....-. --- f ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------•---•--------------------------------------------------------------------------------------------------------------------------------------------------------------"------- 1 -------------------------------------`---------------------------------I---�------------------------------"--------- -----------------------------------------------------------"-------------•------------------ ------ FINAL INSPECTION BY:------------ t`�= f�- -M ---------------- Date------ - -f ;r �� c,. --------------- I 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 ES-9-2M B-51 Revised W-2100 f} l �f