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APPLICATION FOR SANITATION PERMIT Permit No. _�0.. .. 47-1 (Complete in Duplicate) Date Issued Application 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. JOB ADDRESS AND LOCATION_�W: •-•- 1. � . Owner's Name ¢ = ---------•------------------------ ----------------- --------- ------ Phone_ ~ - 4 Address----------------- Contractor's -------------Contractor's Name--------•-•-- - - - -- ------------------------- ............................... • • ---••-•--..._... -_. . Phone................................... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel QOther Number of living units: , ! �__ Number of bedrooms ,�-_ Number of baths /__ Lot size -�__..X.Z�� . Water Supply: Public system ❑ Community'system ❑ Private [?"bepth to Water Table_ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam[Q Clay ❑ Adobe(] Hardpan C] Previous Application Made: Yes [] No New Construction: Yes ❑ No �HA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is a}aileble within 200 feet.) I Septic T Distance from nearest well--.S'D-------Distanc'' from foundation _ Materia) �� . No. of compartments.___ ---- .-.__._.Size.._ _ __�n__-_.___Liquid depth___-- ---___-Capacity._. Disposal eld: Distance from nearest well L? __Distpnce from foundation.b.L2 r Distance to nearest lot line � IR Number of lines_ _.___..j___ __Length 4f each line___.___t�/L!_E___i ___.Width of trench Type of filter material---49; Depth A filter material-------I$_---_---Total length.......... ,/_Q __ __•----------- -- Seepage Pit: Distance to nearest well----------------------Disthnce from foundation....................Distance to nearest lot line___---___________ ❑ Number of pits_ ________________Lining mater iel............... -Size Diameter........................Depth Cesspool: Distance from nearest well---------- Distance from foundation Lining material. _____._. Size: Diameter-__-_ Liquid Ca aci gals. ❑ ------ Depth ------._. -- - - ---------------•- q Caocity Privy: Distance from nearest well_____ ___ _________ _______--___ _______:_Distance from nearest building_____........................._.__.-:____. ❑ Distance to nearest lot line--------------------- c•' ..........•--•-_.__ .....•-- -•----- -- ------ _..------- Remodeling and/or repairing (describe):----- __ -' ------- •-- -•-•----------•--------------------------------------------------------------------------•---------------------------- - --------------------------- ------- --•._.-- ........ ..,_---- I hereby certify that If have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,..r1aws, and rules and regulations of the San Joaquin Local Health District. (Signed) ----------------- By: --- ---- _ • Owner andfo r Contractor) By.:----............................._..__ ----------------------- -------- ---_-•• -•-•••(Title)--------- --- --------- ------- (Plot plan, showing size of lot, to tion of system in relati o wells, bui�Ings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _. DATE f1 , REVIEWEDBY...............................�_.-- •-•-- --� -- - ----- j DATE-•••/. _-'_ ................................ 2. _• Y -T _•_••_•__•• _ BUILDING PERMIT ISSUED ...-r -- - t. – .DATE Alterations and/or recommendations - . ---- 1 ---- •---------- -• •-- -----._._•_ _--- •---- -------------- - -- •---------- -----•---------- -- ---- -- ------------------------------------ ---------------------------............// - --- FINAL INSPECTION BY_____________ _____ ___ Date...... -- _ . --_-.. SA JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Menteca, California Tracy, California ES-9-2M Revisea 1.57 F-P.CO.