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APPLICATION FOR SANITATION PERMIT *mit No. . _Q_____ (Complete in Duplicate) Date issued Applic }' �js�hqrnebya. e to the San Joaquin Local Health District for a permit to construct and install the work herein escri ed-This application is made n compliance with County Ordinance No. 544. - - 3.t Sam ' R, �, ern. �I d �, ' _ —a'-+�e JOB ADDRESS AND OCATION...-----&t- ---- - ,. ------ - .� , - .__ __ m. - ----IP`,1 i.... --Owner's Name---_----- - -- -�C:P�------- ----- �{ - --- -- -------------- Address----•--••. �" -,:daad- ----•-----------t--< r -� -2-_( Cf _� Contractor's Name----f'-u_j-.:?t Phone Installation will serve: Residence Apartment House ❑ lop ommercial ❑ Trailer Court ❑ Motel [I Other ❑ Number of aths -/�-. Lot size _--_ Number of living units: __/-_ Number of bedrooms _. Water Supply: Public system E] Community system El 'Private "Gpth to Water Table . ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam V Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑`. Previous Application Made: Yes ❑ No V' New Construction: Yes W No ❑ ` TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public,sewer is available within 200 feet. �� ---Materiel ----- ----------------------------- Septic nk: Distance from nearest well_,___.....Dista e fromf ounda�ion_.. __ __ f No. of compartments.._. ----------- ---SEze_ .1Y> _ '- ___.Liquid depth.----- - -------------CapacitY---- * - y ��y 5 / f'd Disposal "field: Distance from nearest/ell---- ---_-.__Distance from foundation -- ___.-.__..Qistance to nearest,Ipf4ne �r _..- -- - ----_--. Length of each line----- — ----- -----.Width of trench• --------------------- DO ----------- Number of lines______..__ �� Type-of filter materia .__ Depth of filter material_____; ____:_..Total length------ C __ _____________________ Seepage Pit: *Distance to nearest well------ --------------Distance from foundation.-..----------------Distance to nearest lot line-- ---- --------- r ❑ Number of pits----------------------Lining material-------------------._..Size: Diameter-----------------------Depth. r Cesspool: Distance from nearest'well-----------------Distance from foundation---_--------------- Lining material----------------------- :----------- . s ❑ Size: Diameter,-------------- -------------------- ---Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from rearest well--------------------------------------------------Distance from nearest,building-------------.---------------------------- ❑ Distance to nearest lot line------ - ------------------------------------------------------------ ------------------------------------------------------------------------ Remodeling an`d/or repairing (describe)-------------------- ------------•- ----------•------------- ----------------•---- -----------------•---._._..-------------------•---- --------------------------- -----------------------------------------------------------------------------------•-----------------._...-----------------------------------------------•------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District, (Signedy. ------- -------------------------------------- (Owner and/or Contractor) f 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 _ ---•-------------- w l BUILDING PERMIT ISSUED--------------- ------ DATE-------------`-_ •---------------------------------_-- Alterations and/or recommendations:. - ------------ ------------ 1 r ----------��------------------------- ------------------------------------------------------------ ----------------------••----------------------------------- --�-�� -�'� /�-=�:-._?__ ._��----•---- - ----•---�--• ...... . ... ... ------ ---------------- --------- -�----------------- --------------------- ------------------ FINALINSPECTION 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 51514 ATW..P y�