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APPLICATION FOR SANITATION PERMIT Permit No. -S.. aF ti9 (CompleW in Duplicate) �f 1 Data issued ___. Applica+ion-is li6-reby-m' ade to-th-e-San Joaquin L"ocal'Health District for a permit to construct and install the work herein described. This application is made in compliance,.with County Ordinance No. 549, P. Io xSa-- ' T LOCATION. .. rJOB ADDRESS AND ----------- Owner's Na'me------------------ -----� �--- - e t ------ Phone.--- Address.....- � TT .?r :` -a' ---•-•------------------------- -••- J. - Contractor's 1 NameYs ` Phone ---------------------------------------- Installation : will serve: Residence Apartment House ❑ t Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . Number of living units: __f.__ Number of bedrooms .Number of baths/_____, Lot size ____._____ �_n_x__h _ ____________________ Water Supply: Public system E]j Community system ❑Ys PrivateX Depth to Water Table -------- ft. Character of soil�+o'a depth of 31feet: Sand-❑Y Gravel ❑' Sandy LoamK Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No,�aj.- New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within.200 feet.). Septic Tank: . kDistance from nearest well._:_�_ �istance from foundation-_._/_0____.__.Matefial__. --_.___--_ �. Size._ _S Liquid depth- -��--------Capacity------- ------ i No. of Lomparfinents........_ Disposal Field: Distance from nearest we _�`_�-----Distance from foundation_---.109---._._.Distance to nearest lot line-----._f__—____. Number of lines------ _._._..______ .-___:.Length of each line__--_____- --.."__.Width of trench.__-------'Z-��_-.--- -- Type of filter material-- ."Depth of filter material-._._._-_ ....Total length------------------?W—_-Z* Seepage Pit.` Distance to nearest well-------- _____________Distance from foundation....................Distance to nearest lot line__--_.__-_-_. ` ❑ Number of pits----------------------Lining material-----------------------Size:.Diameter-----------------------Depth------.----------.--------------- Cesspool: ! Distance from nearest well-----------------Distance from foundation------------.------ Lining material--_:r.--------------------.------------ _. Size: Diameter- =-------- ----------- - ---------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well. ------------------------------Distance from nearest building__-...----_-.-------__---__-_-._.----._. ❑ Distance to'nearest'lot-line-------------c:-. Remodeling,and/or repairing {describe):--------------------------------------------------------------------------- ---------------------------------------:-------------------------•----------- ----------------------- ---------------------------•---------------------------------•-,----------------------------------------------------------------- ---- -- --------------------------------------------------------------------------------..-------.-------------- -------- ------•--------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 laws, and rules and regulations of the San Joaquin Local Health District. 1, ( / t 5i ne ,may, _ ---------------------- Owner and/or Cd on Tactor � �Y• ------------ Title ----------------------I------------------------------------- • _------------•---------_ --- ( } (Plot plan, showing size of lot, location of system in relation to wefts, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------- --- - ----- ----=-----------------------------------•-------------------- DATE------ ------ --- -- ---- --- ---------------------- ---------------------------------- REVIEWEDkBY; ------------------------------------ -------------------- DATE---•----- -------------=---------- BUILDING PERVIT ISSUED -- DATE Alteratio s a,n /or,recommendations:._..__... .......... ..... .. -- �..e �� 7 _ L� . a-. .__.... ' ...../ ------ -_5,\---�-------- k1 _ - ------------r_ NO ' ------------------------------------------------------------r____.____._--._..---.-_.--- ------------------------------------ ------------------------------------------ 1 ________________________ __ -------- ____....---------- _._-------------------------_____..____..__.._.._____-_._____.._.__._____._.._._.._...__ _______.._._._.--------- jj FINAL INSPECT,I ,. Y: ----------- ----- Date Q SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street.. 300 West Oak Street 132 Sycamore Sfree+ 814 North "C" Streof Stockton, California, Lodi, California Manteca, California Tracy, California i E5-9-2M 145446 A7WOOD 12-s4