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1 APPLICATION FOR SANITATION PERMIT Permit o. 4- ---------------------- (Complete __-___-_-.(Complete in Duplicate) —5-( —S(o Date Issued ----�---------------- 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 with County Ordinance No. 549, rtt b b �5- F74�e V 7-•- S_/_T o q 2-0V 3 JOB ADDRESS AND LOCATIO ------------------ --- __ _ . ,_ f T- - ---""'-`-rte,`�--------------- ----- -------------------------------------------------------------------- -------------- Owner's Name _;: '� '` ;-�", `��"` Y± r� -------- L„-------- ----------- Phone------------------------------------ Address------------------- __ -------------•-----------------:------------•------------------------•--•-------------------------------------------------------------------•----------•---------------- Contractor's Name....... ------------------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 2--- Number l} — Number of living units: ------ Number of bedrooms -------- Number of baths -------- Lot size _____ ___._a.------ __________________________ Water Supply: Public system (Community system ❑ Private [] Depth to W ter Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No DR-` ew Construction: Yes ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) p // � Q AP Septic Distance from nearest well -_-..-Distancesfrom foundation._ _._a----_____,M/aterial_________________ No. of compartments------ . _�----------Size-J___X-07-�� ------Liquid depth__,!----------------------Capacity_/A A15-I-. Disposal Field: Distance from nearest well__ .. Distance from foundation A0 ---- Distance to nearest lot line., '_ ' _. Number of lines-------------- - �- .- __ - �________________Length of each line___ U` .-- Width of trench--.Y- ------ .---_--------- Type of filter material_ " - -Depth of filter material__ 8.�.�_- Total length------I0-Q+______-___________-- 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________________D'€stance from foundation--------------------Lining material------------------- -----------.__-_.. f ❑ Size: Diameter--------------------------- -- -------De_pth------------ ----------------------------------- ---Liquid Capacity-.--_---------------------•--gals. Privy: Distance from nearest well_______________ ~------.__------------Distance from nearest building ❑ Distance to nearest lot line----- -----------------.-.------------------•-•-•-----------------=----•---------------------•-------- --------------------------------- 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. (Signed) ------------------------------------------------- ----------------------------------------------------------- ----------(Owner and/or Contractor) By-------------------------------------------------------------------------------------------------------------------------------------(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------ ----- ----------------- -•------------------------------------- DATI -------- --------- REVIEWEDBY-------------------------------- --------------------------------------------------------- DATE .. 3W- -- -----------•------- BUILDING PERMIT ISSUED------------- ------ DATE----------------------------------------------- Alterations and/or recommendations:------------------------------- -•---------------------- --- --------------------------------------------------------•--------------------..._.-,.. v�� } ----------------- ---- . ---F------ ._..-- - -----�- --- - .---'- ---- -------------- - - -- '-- L� --•-•------------ -- - - ----- --.. - - - ------ -- - /-o - s — ,�. ------ ------------------- FINAL INSPECTION BY -----------------•------- ---- ---------- Date..../��---r-r -~----(-------•------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9 145446 ATw000