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- 41 �, �APPIICATION FOR SANITATION PERMIT Pe it No. !._,�d___ _ ' a - 5 OILI (Complete in Duplicate) �' I 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 Ord& nce No. 549. JOB ADDRESS AND LOCATION------ -_ rt_--_ - j l�tr-c .► --- ------- - ------------------------------------------------ Owner's Name '-%------ G------ fZ ,.. .--------------- Phone-- Address - . -------------- ----------------------------------------------- Contractor's Name___________________ -- ------•--- ` - --..._�.---- Phone-------9 �-- ' Installation will serve: ResidenceX Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _ Number of bedrooms _ Number of baths J_--- Lot size Water Supply: Public sysfemR Community system -❑ Private ❑ Depth to Water Table'",v ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ CIm E] Clay Adobe,* Hardpan E]Previous Application Made: Yes E] No)e�.• New Construction: Yes E] No p TYPE OF INSTALLATION AND SPECIFICATIONS: 9, (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material--- 1 ❑ No. of compartments ----------Size----- --------------------------Liquid depth--------------------------Capacity Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----------_------ ❑ Number of fines-----------------------------------Length of each line-----------------------------.Width of trench----•--------------------- 4 , Type of filter material______-__,_ Depth of filter material----------------- --Total length-------------.--_-_.._--- -_-.-_ _- N Seepage Pit: Distance to nearest well--._- __. QDistanc f fo dation--- -_ � � ._.--.D�is nce to nearest lot liner- Number of pits------- ------------_Lining material __--- _Size: Diameter-.---?�o -°'_De th-_ �' V 1 p -- ---------------- Cesspool: Distance from nearest well---------------- Distance from foundation--------------------Lining material-----_.-___-----___----_--_.---___.-. ❑ Size: Diameter------------------------------------ Depth---•----------- ----------Liquid Capacity----------=----------------.gals. - -------------------------- I Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin 9 ❑ Distance to nearest lot lin _____-___-__ Remodeling and/or r paging [(cribe):-_ --___ _ �j �#7 --L:C•('� .- ? awe 1 ------ - -_ '�`�`� --- ....... �h -�,.��.----------------1�-------------------------- ------------------------------------------- -- ---------- -------------------------------------------- --------------------------------------------------------------------------------•------------------------------------------------------------- --------------.---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, State laws, and u :)and regulations of the San Joe,quin Loca Health District. (Signed) = = J a ,0 ----------------------------------- BY: "T - ------- ( ontractor) --------------- Title + - � (Plot plan, shows g size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY [ APPLICATION ACCEPTED BY�__------ DAT REVIEWED BY ----------------------------------------------------- :---------------- DATE-- -, BUILDING PERMIT ISSUED--- -------------------- Alterations and/or recommendations: --• DATE--------41% = ------------ ----------------------------------- ---------------------------I------ ------- FINAL INSPECTION BY _.-__-__-__- .� -------------- Date_ ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 SouthAmerican Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton; California Lodi, Caiifornia Manteca, California Tracy, California ES-9=2M 8-5I:Revised W-2100