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APPLICATION FOR SANITATION PERMIT Permit No.NY `V (Complete in Duplicate) y�9S7 Date lseued-___>__ -- _.//--_ 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. 9 . ----------JOB ADDRESS AND CAT N d -vOwner's Name-.,--------------- - --- ------------ .- Phone 1 Addres ------- -------------•-- ----.. Contractor's Name --'__ `-- -•- ._... - . Phone _& Installation will serve: Residence [P--`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /-- Number of bedrooms .c Number of baths .r k Lot size.---.7.6 ---------4_D`------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ::95 ft.. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam ❑ Clay ❑ Adobe �Iardpan ❑ Previous Application Made: Yes E❑ No [ New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) e is ank; Distance from nearest well-- ---_---------Distance from foundation-------------------Material-_--_---...-_-_--___.-_----_-_--_-__.---_---_-_. No. of compartments--------------------------Size------------------------------..Liquid depth---------------------- - Capacity----------------------- osal ie d: Distance from nearest well.-..--_---- _.._Distance from foundation--------------------Distance to nearest lot'line----------------- ' Number of lines-----------------------------------Length of each line---------------.................Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material------------...........Total length------------------------------------------ Distanc om oundation..... .........e-__.Distance to nearest lot line-----�f�_-... Seepage Pit: Distance to nearest well. _ __ .-_ �f -� ❑� Number of pits----- ___________Lining material_ 1�.Gr°1 .....Size: Diameter--- .._.-------Depth__a ------------__-___._--._ � Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material--..-__....___---.-___---._--__-_-_ fI ❑ Size: Diameter---------------•----------------------Depth--------------------•-------------------------------Liquid Capacity------------------------------gals. \� f Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-__--_-_--.-_.-----_-_..._ ❑ Distance to nearest lot line----------------------------•---------------_--------------------------------------------------------------- ---------------------------- Remodeling and/or repairing (describe)----------------------- ...............- - --------------•---..............----------------•-------••-----••-•------:--------•- -------------- ---•-----•----------------•--------•-------•---•--------- -----------------------------------------------•---------------------------•-•--------------------------------------•----------------•-----------------------------------------------------------------------•---------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S laws, and rules and regulations of the San Joaquin Local Health District. (Signed)--------- ---- - -------------------------- ---- �... - - ------- --(Owner and/or Contractor) BY: 1..l�...... � ----------------•--------------=----------•-(Title)----"--� ---------------------------- -- ------------ (Piot plan, showing size of lot, location of system i relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ------------------ --- ------------- DATE---- ?1------------------------------ ----------------- REVIEWED BY - - -------------------------------- DATE----------- BUILDING PERMIT ISSUED---------------------------------- - DATE--------- ._ f Alterations and/or recommendations:---.--- ----:--- •----� .... -� ---------------- _-- ---------------•--• ----- - ----------.- - �= ------------------------------------- ---- - - - - --------------------- ---------- FINAL INSPECTION BY:-- -------•--• -------------------- Date-- � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oek Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E 5-3 145446 ATWUUD