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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued .7__�J I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the� k herein escibed. * .is-ap .lication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION...___ �, Owner's Name------------ .u°-�-�_--- �f_n.��_i��-="' r+� --------------- rq---- Phone-----`51--� Z2 Address-------------- --------------------•-------------------•-------------------------------------------------------- Contractor's Name------------------------------------- �� rtrt I"'-------------- - -----------� - ---------------- Phone--------- ------------------------------------- - -------------------------- nstallation will serve: Residence E] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other. .S' Number of living units: -------- Number of bedrooms -------- Number of baths ________ Lot size _____________________________- Water Supply: Public system [:] Community system E] Private 4 Depth to Water Table -------- ft. .Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ® ' Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes,4 No ❑ New Construction: Yes ❑ No'n p TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic Tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-A00 �_-_Distance from foundation_____- —, p Material Q,-�----------4 Rr No. of compartments---------a,-----------5ixe___ X_ _ "--------Liquid depth---------/,kC Disposal Field: Distance from nearest well-IQD_#__-.-_Distance from foundation___-��-----------Distance to nearest lot line----- 2-_'_ Number of lines-------------t•[ Length of each line----------vo-D ---- Width of trench------- Type of filter materia(_�k'�___}7L�_-- - __Depth of filter material------ _�`'�_----------Total length-----------0 Seepage Pit: Distance to nearest well ___------------------Distance from foundation-------------------- Distance to nearest fat line ED Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------.Depth--------------------------------- _7 Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------------------- EJ Size: Diameter------ -------------------------------Depth--------------------------------------- -- • ----Liquid Capacity-------------- - - ----------------------------gals. � Privy: Distance from nearest well--------------------------------------------------Distance from nearest buildin El g Distance to nearest lot line1 ` ------------------------------------------------------------------------- Remodeling and/or repairing (descri e) �_� a . J1 41 N n -- -A --- ---- - -------------- ----------- ,.,.e------- ::-I. - --- -------:a- �.__ -►� ►�= .-�------------------------------------------------------------------- I hereby certify that I have prepared this application and .that the work will be done in accordance with un San Joaquin Coty ordinances, St a laws, and rules and egulations of the San Joaq n L cal Healflh Di ict. (Signed)------ --------- -- --------- - --- -- .. .(�r and/orContractor] --- -- -- -- -- - sY� --- - --�-- ----------------(Title) (Plot plan, showing size of lot, locatio of system in relation to wells, buildings, etc., can be placed on reversee).r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY____________________ -- _ --------------------------------------- DATE ---9-7-----`-----�:---- REVIEWED BY -------- ------------- /� f BUILDING PERMIT ISSUED-------------------- ------------------------ - DATE----- ------------------------------------------ --------- ------------------------------------------- �. --------------------------------------- DATE_------------------------------ ------------ 1 Alterations and/or recommendations:____________________ ------ --------------------------------------------- ------------- .. - -- --------------------------- - - - -------------------------------- --- -- -------------------- --- - - FINAL INSPECTION BY:_____ _`�-- ---------------------------------- J ----------------------------- Date_.--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M 13-51 Revised W-2100 I