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APPLICATION FOR SANITATION PERMIT Permit No. -----71-x._Z. (Comple+l in Duplicate) V�A414.Da+e Issued __._ Application is hereby made to the San Joaquin Local Healt District for a permit to constr and install the work herein described. This application is m de in compliance with County Ordina c No. 549. JOB ADDRESS AN OCATION.... _-----___-- _ Owner's Name .. ---•-- - ---------- -------------- Phone--------------------------- Address----------••--------------------------- ---- ZN4 —• Name............... ---------------------- Installation will serve: ResidenceApartment House ❑,, /Cpmmercial ❑ Trailer Court E] Motel El Other E]Number of living units: ----- ._ Number of bedrooms .__ -_-_ Number of baths .__!__ Lot size — ------------- ----- Wafer Supply: Public system [Community system ❑ Private ❑ Depth to Water Table --- ---- ft. Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑ Sandy Loam ❑ Cla Loam ❑ Clay ❑ Adobe �ardpan E)Previous Application Made: Yes.❑ No New Construction: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: 7" . (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----------_----_Distance from foundation-------------------.Material ___---------- _---.____________-_-_____.-___-. ❑ No. of compartments----------------------- --Size-------------------------------Liquid depth------------------------Capacity Disposal Field: Distance from nearest well_________________Distance from foundation-------------------.Distance to nearest lot line----------------- F1 Number of lines-----------------------------------Length of each line------------------------------Width of french-.--------------------------------- Type of filter material-------------------------Depth of filter material----------.___---------Total length_______..._________-_---_ ------•--•------- Seepage Pit: Distance to nearest well----------------------Distance from foundation__......___________.Distance to nearest lot line----------------- El Number of pits------ ------ - ng material--•--------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from neare wel . ---------------5istance from foundation____----___---------Lining material-_.---________.____.______-__.______ . Size:-Diameter----------- --- ---- a'-.'6epth-------------------------- -- ----------------------Liquid Capacity------------ gals. Privy- Distance from nearest we'll___-__ ------ ""`""" "'.�E)istance4fromrnearest building._____---------_-- _____________ ❑ Distance to nearest lot li .------- - ------ -------------- ----- --------------- , R Re odeling and/o re airing (descrii�e): = „J� - ----- ------------- . ................ .---------- - -------- .... _- - ---------------------------------------------- ----------------------:---------------------- :::: :: I hereby certif that I have prepared this application and that the work done in accordance with San Joaquin County ordinances, State a s, nd rulef and r lations of th San Jo Local Heal District. (Sign 9 d) { t. V-_ill Owner and/or Contractor) l � ( / 1 By:-------------------------------------------------------------------- ----(Title)- --� (Plot plan, showing.size of lot, location of cyst i ation to wells, building , e+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- - --------- -----------•----------------------------------- DATE------- - ---------------------------------------------- REVIEWEDBY---------------------------------------------- ---------- -------------------------------------------------- DATE--------- BUILDING PERMIT ISSUED----------------------- ------------------------------ DATE--------------- Alterations and/or recommendations:------- ------- ----- ------ ------- ---- -------•-----------------------------------...------------------- ------------------------------------------------------------------------- ----------- ----- ------------------- FINAL INSPECTION BY:. .Cw:�.- f �---------------------------------- Date... --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4-2M 145446 nTwoao 12-54