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i APPLICATION FOR SANITATION PERMIT Permit No. ....7................. / co (Complete in Duplicate( 3/ ,y 4 � 11 Date Issued N ~ Hpplica4.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 compl'an e with County Ordinance No. 549. C �T74 S I ° te,� l JOB ADDRESS AND LOCA r / d----,-------- ... !"---"�--- `•-=--- -- ---------------- ---•---------------- Owner's Name------- -- - --- -----•-- ..--- ho e ------------------------------ Address--------------- a . .`7!'._... .----- ------------------ ----------- f Contractor's Name------------------- ----•----------- ---------------------------------------------------------------------------------------- P ne..------•--•----------------------- InstaHation will serve: Residence artment House ❑~ . Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _)---- Number of bedrooms _-umber of baths --?---- Lot size _-- C2 __ j---Q_:n--____-___------_-_.---_ Water Supply: Public system ❑ Community system ❑ Private F4—UD pth to Water Table �_ ft. Character of soil to a depth of 3 fest: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Ciay ❑ Adobe � dpan ❑ Previous Application Made: Yes ❑ No (_ New Construction: Yes a\ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public Iewer is available within 200 feet. Septic nk: Distance from nearest well- S -..--Distanc from foundation---j; -----------Material - -------_.. No. of compartments_-------�.--.__._.__Size-- _ --.5____Liquid depth Capacity__ -O_____ // Disp I Field: Distance from nearest weH---A.-5�Distance from foundation----- --Distance to nearest lot line---z� (�� Number of lines---------------- Length of each line---- -_ - ---.----_ (-Width of trench--.-... ..------- ��CCC Type of filter material.-.-.', _ --- __ _3Depth of filter material--------- Total length---.----��'�--- ------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot li ---_---_--_.-_-.- 4�, ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth---------------------------------- - Cesspool Distance from nearest well-----------------Distance from foundation------------------. Lining material------------------------------------- _ Liauid Size: Diameter-------------------------- --------- �epth-- � - -Li uid Ca ac ale- - - --- - - - -- - 1 Privy: Distance from nearest well._----------------------------------------------Distance from nearest building — ❑ Distance to nearest lot line--------------- --- - - -------------------------------------------------------------------------------------------------------------- ---- 1, Remodelingand/or repairing (describe):------- ---------- -------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------- ---•------------------------------------------------------------------------------ - I; ------------ -•-------------------------------------------------------------------------------- --------------------------------------------- ----•----------------------------------------------------------------------- !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 I w and r es and regulations the San Joaquin Local Health District. Owner and/or Contractor (Signed)!-- .,e-,,, r = =_41 ( / ) BY� -------------------------------------------------------------------------(Title)------------------- ------- ------------- --- ----------------- (Plot 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----------------------- -- REVIEWEDBY------------------------- ------------- --- -------- -- ------------------- DATE -------------•---- DA7EBUILDING PERMIT ISSUED-------------------------------- - ----- Alterations and/or recommendations:.------------------ -- V ---------- --------•------------------------------------ ------------------------------------------------------------------------------------------------•--•-------------------------------------------------------------- - --------------------------------------------------------------------------------------------------••------- FINAL INSPECTION BY-- --- --------- ----- - Date------- l ------------------------ 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 E5-9-2M 145446 ATWCOD 12-54