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' APPLICATION FOR SANITATION PERMIT Permit No. ... !-. l'.-...-_- ' (Complete in Duplicate) q Date Issued ._- l" Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. I This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION-- I E �.- Owner's Name kx-�., �� - ----------------- --- Phone. Address-----------------------------1.---L-� t.�1 �� '�� ----------- Contractor's Name---------.Q. }..kms _��.------------------------------------------------------- ---------------------------- ---------------- Phone Installation will serve:. Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ 'M otel ❑ Other ❑ Number of living units: __I__-_ Number of bedrooms --YNumber of baths ---I--- Lot size ---r7- "` '- X----I-��--_ ------------•-- Water Supply: Public systemCommunity system E] Private ❑ Depth to Water Table ------- ft. Character of soil to a depth on3eef: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ ' Adobe Hardpan P ❑ Previous Application Made: Yes ❑ NoV New Construction: Yes�No El TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest w•ell_ -----Distance from foundation_----)--Q_........Material----2_e---j-..W_Q-"" l----------- K, No, of compartments.--_.____-y -.---Size-__ _ _.__ - ---Liquid depth-------"- ---"-Capacity Disposal Field: Distance from nearest well..-SM----Distance from foundation----it----------Distance to nearest lot line----- ____-. Number of lines--------.---- - _- ngth of each line--_4.__0_______________.Width of trench_._.__ Type of filter material-,�� -k1$tl�,o�filter material----I-�-----------Total length___._"" "�}-----(----------------- Seepage ---(----------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------______.Distance to nearest lot line__.------_____--.- i i Number of pits---------------- --Lining material----------------------.Size: Diameter-------------------+"--Depth---------------------------"-•_-• Cesspool: Distance from nearest well------ ---------Distance from foundation----------.---------Lining material_..__--.._._ \ ` ❑ Size. Diameter-------- ---- ---- --------- ---------Depth------ -------------- --- ------------------ - ------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------.------- ---------_---_-___.- ❑ Distance to nearest lot line-------- ------------------------ ------------------------------"-_ Remodeling and/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. (Signed)----- - ��` F_`" --- ------------------ - -----------------=--- ------------------------ ------ -----------(Owner and/or Contractor) � By:. •------------------------------------ ------------(Title)---------------------- ------- [171ot pian, owing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY----- --- -------------- ------ ----- --------------------------------------------------- DATE-----�------------------ ----------------------------- REVIEWEDBY-------------------------------- ----------------•--------------------------------- ---•-------- DATE--- BUILDING PERMIT ISSUED----------------------- - ----- ---- - --- - DATE.. �tf Alterations and/or recommendations:_____________.__..._----........... ----- --- ---- - -------------------------- --------- --- - -- - ----- --- - -- --- ------ m- � ------------------ FINAL INSPECTION $Y: Date = ------------ -- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, Cafifornia Lodi, California Manteca. California Tracy, California Es-9�-2M- 145446 ATWf 11 12-54