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APPLICATION FOR SANITATION PERMIT Permit No. ...r f - * %AT (Complete in Duplicate) fG Date Issued _________ _ _______ 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 yN�o�. 549. JOB ADDRESS A D LOCATION_•.-_.._.! ___3�__. _..-�@, _..f_f-Gi�, -_••••_-___-•__• _ Phone -----•••••- Owner's Name..__ r f!\,!............. a Address........c2Aq-q•................. ••--••-- Contractor's Name........ ----- ••. ---- - ------- ------ •-------------------------------------- Phon (0_-.Q _7 Installation will serve: Residence [4 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _- ._.._ Number of bedrooms -__}' Number of baths ----l.. of size _.�-----X_/t?_a________________________________ Water Supply: Public system ® Community system E] Private E] Depth to Wate Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam E] Clay Lo m ❑ Clay ❑ Adobe, ) Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes ❑ No P TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: ' A r Distance from nearest well-_;______________Distance from foundation....................Material ____.._____..______.___.___._..___._.__.___.__._. r . of compartments--------------------- ----Size--------------------------------Liquid depth---•------ --------Capacity....................... Disposal Feld: Distance from nearest well_________________Distance from foundation•._----•.-_------._.Distance to nearest lot line................. ❑/' r of lines-----------------------------------Length of each line------------------------------Width of trench..................... Typ(9'of filter material--------------------_____.____,Pep h of filter material--__.__ ____.__.__ _To al lengt __......._. __._.._._ Seepage Pit: Distance to nearest well----oz___ ---------�istance rom oun a ion__________ __ istante to nearest lot line_____- [� Number of pits_.......)-----------Lining material _. _____ L Diameter-__--33. ---Depth .....��_____________ Cesspool: Distance from nearest well-----•-----------Distance from foundation--------------------Lining material•-.-___•-..__-:_____--._--.-__-••---. ❑ Size: Diameter-------------------------------------- Depth-----------•----•---------------------------•----._.Liquid Capacity---------------------------- 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 �4 ordinances, State laws, and rul and regulations of the San Joaquin Local Health District. (Signed)_--•- -•----- • -------- - --- - -- ------- -- -----------------------------------------------------------------(Owner and/or Contractor) By:.................................L------- - Title----- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- - -----------------------------------------------•---------- DATE........ --------------------------------- REVIEWED BY----- ------------------------------- � DATE............••. _. BUILDING PERMIT ISSUED............................. �\ - ------------------------------------------...-------------._ DATE------------------ ----�-----------------------------•--- Alterations and/or recommendations: ........ ... . -- ---- ------ - --- - ------- - -- -- - 6 ------ ---------- c,.—, c� . o?lk.1-two Tui - - -.. ----•••--- : --------------- -------------............................................................................................................... ----------- ------�'-------------- -•---- ----------- --------------------------------------- ---------•-••••------•------•••---•---•---•---•--••-------•--------•-••------•---••........................-••---••••. FINAL INSPECTION BY:----------------- -----------------------4-------- ------------.. 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 J ES-9-2M 145446 ATWDOD 12-54