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4- APPLICATION FOR SANITATION PERMIT Permit No. .__, a3--•_-. (Complete in Duplicate) /0 Date issued .__.. 1/__�'�______. 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 it pounty Ordinance No. 549. F[,�u6�77{ ST- ' JOB ADDRESS AND L CATION------- -- ------- ----------------------------------------. �� ------Owner's Nam _ Phone---------•-------- ---- --- - ------------ - r--- •----•------ -------- Contractor's Name --�- ---------�--�•----- -----••----------- Contractor's Name---------------• Phone----------------------------------- Installation will serve: Residence ❑ partment House ❑ Commercial ❑ Trailer Court Motel Otther ❑ Number of living units: 1-0 Number of bedrooms Number of baths ._ Lot size __ - - __ _._ _ ____1---------------------------•-� Water Supply: Public system� Community system C] Private F1 Depth to Wafter Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam ❑ Clay Loam ❑ Clay Adabe❑ Hard an E.] Previous Application Made: Yes ❑ No K New Construction: Yes 0 No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wi+hm 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material---------------.---------_--___---_-------_-.._. ❑ No. of compartments-- ---- ------------------Size----------------------------•---Liquid depth.---------------- -------.Capacity------- ------ Disposal Field: Distance from nearest well-----------------Distance from foundation_______._______...._Distance to nearest lot line--------.-------- 0 ❑ Number of lines-----------------------------------Length of each line-----------------------:------Width of trench----------------------------------- Type o£ filter material.___----------------_--Depth o£ filter material ._._____-__._.._Total length------------------------------------------ �1 Seepage Pit: Distance to nearest well---------------------Distance from foundation--------------------Distance to nearest lot line___----___-----_ ❑ Number of pits-------------- ------Lining material-------------------- Size: Diameter-----------------------S ize: Depth--------------------------------- ._--Distance .... Ditffoundation .. ............. inin material----- -- � _esspoolS Distance from nearest well--- g �� LiqLiquidCapacity_..a Q-o----------- els. 15�j .�i�rr r�1ke r.e2l'1.r-f`- '�-------- p m _ _ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ F-11 Distance to nearest lot line...... - ------------- --------------------------------------------------------------t------------- ----------------------------------- `l -41 Remodeling a; or repairing [describe): -- 'e'.... ... 1r 5 -----£'� . . ------------------ . � ® - tS ------------------------------------------- 1 I hereby certify that I ha�i prepared this application and that the work will be do in accordance with San Joaquin ounty ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----- Q (r�� - ---------- -------------- ---------- ------------------ ------(Owner and/or Contractor )�, By:--------------------------- ---- -- -- -•--- -- ----- Tale -- -- - - - - --------------------------------------- -------------- ------ -- (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---------- --------- ------- ------------ A� DATE----- -----...^- } --- -------------------------- REVIEWEDBY------------------------- -------------- - - ------------------- -------------- DATE _a_ BUILDING PERMIT ISSUED--------------------------- ----- __. - _._ - --------------------------- DATE Alterations and/or recommendations--------------- --- -- ----------•------------------------ -----------•---•----•----•--••---------------------------------•----------- ---------•------- ------------------------------------------•-.------------------------•--------•--------------- ------ --------- --------------•------------- ----------- --------------- ----------------------- ---------------•----------- --------------------------- ---- --- -----•=-- -=" %-------------------------I----------------- -------------------------------------------- ------------------------------- - �- s - - ._ FINAL INSPECTION BY:_----- . ----------- --- -------- Date. ------- -------------- - 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 145146 A-DD- 12.54