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' �� VAPPLICATION FOR SANITATION PERMIT Permit No. -,;1-45--- <, _I (Complete in Duplicate) Date Issued k ' . Apeby made to the San Joaquin Local Health District for a permit to construct and install the work herein descr plica+ion is heribe � i This application is made in compliance with County Ordinance No. 549"�- y JOB ADDRESS AND LOCATION----------- ___ ----------------------------•--------•--- t -. - Phone------------•----------------------- Owner's ----------•--- •------ , ----------------------------------- Owner s Name_. = ---- -----•--------- Address= - Phone------------•---•--------•---- ----- Contractor's Name--------------- -•------House ❑ Commercial ❑ El [I------------------------------------------------ l Trailer Court Motel Other 9+; Installation will serve: Residence 0 Apartment ..—..-- -- 1 � - -------------------- Number of living units: _Number of bedrooms Zi_ Number of baths ___ _"" Lot size _____________________ ' Private ❑ Depth to Water Table _____-__ ft. Water Supply:- Public system Community system 0 -"- Character of soil to a depth of 3 feet: Sand ❑' Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 'far-span ❑� Previobs Application Made: Yeslow❑ I New Construction: Yes 2-1170 E, TYPE OF INSTALLATION -AND SPECIFICATIONS: (No septic tank or cesspool permitted if pulzric sewer is a ilab r� •2 .) feet.) Septic T k e fr m n ee a ________________V- 1 It from oun a i n____`___ ----- Material------------------------------------------------- No_ of compartments Size ------------Liquid depth Capacity Ate" J-0-17---Distance to nearest lot line t�"��-- Disposal F•-1d: Distance from nearest well ' n? -Distance from foundation___ Width of french__.____A-44ti- ----------- Number of lines-----------'Y ai---------Length of'each line--------4-0---l J----- a Type of filter material____ Y --___-__:___--Depth of filter material--___I--- -----------"Tata! length------- "-•-- _•-- Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line----------------- Seepage ----------Linin material-----------------------Size: Diameter-----------------------.Depth ❑ Number of pits______.____ g Distance from nearest well________--______Distance from foundation------------------- ning lel Cesspool: gals. ❑ Size: Diameter-------------------------------------Depth--------------------- -- ------------------- Liquid Capacity --------------------- ________---_ ___""_________________Distance from nearest building------------------------------------------ Privy: Distance from nearest well___________ ( ----- ❑ Distance to - _ nearest of ine____.. --------------- ------------ ------------------- -------- ------------------xx Remodeling and/or repairing_(describe]:_____________- --- -- -- " " -------- - --- --------------------- -p pp Joaquin Local Health District. q . ----------------------------- -------•---------------•--------------------------------•-----------------------------•------ t ! hereby certify that I have prepared this application and +hat the work will be done In accordance w1+h San Joa um Cour.;-{ ordinances, State laws, and rules and regulations of the San q ? 9,0 (Signe � . ------------------------------------(Owner and/or Contractor). ned Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t:. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ----------------- -------`- --- -------------------------- - DATE---------- - ----------------. DATE---------------------------------------------------` REVIEWEDBY------------------------------------- --------------------------------------------- - -- ---------- - , BUILDING PERMIT ISSUED--------------------------------------------------------------- --------------------------------------- DATE------------------------------------------------------------- - ---------------------------------------- Altera+ions and/or recommendations------------------------------------- --------- ----------- -----=------- - ---------------------------- ------------------------------ --- ----------------------------------------------------------------------------------------- FINAL INSPECTION BY__________________ ___ �'-k�-- -- F Abate K SAN JOAQUIN LOCAL HEALTH DISTRICT t 300 West Oak Street 132 Sycamore Street $14 North "G" Street 130 South American Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4--2M 8-51 Revised W-2100