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APPLICATION FOR SANITATION PERMIT Permit Na.vp �•--� � s letn Duplicate) Date issued ---•�_ ` (Complete iI p F / hereby made to the San Joaquin Local Health District for a permit to construct and install.the work herein described. Application is he y i This application is made in compliance with County Ordinance No. 549. " .... ------- ' TI ...- _ '---------------------------- JOB ADDRESS AND LOCA thone------------------------------ Owner s Name -.._ -- -------------------------------------------- - - .. .. - ------------••--------------------------------------- ---- - --- --- op -------- Phone--- Contractor's Name_---- _,- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ . �` D� - 1�--069 ---------- Number of living units: _= Number of bedrooms ��Number of hs 1X_ size ___-- .: + Private De th to afar Table�Ll. ft.l . Water Supply: Public system ❑ Community system ❑ P ❑ Adobe and an Character of soil to a depth of 3 feet: San Gravel ❑ Sandy Loam Clay Loam Clay ❑; P ❑ Made: Yes No �w Construction- Yes No ❑ Previous Application Mad ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool}permitted if public sewer is available within 200 feet.} Distance from}nearest well------------- Distance from foundation_----_-------------Material_.--:-_.-_------------------------ --------- Septic Tank- Liquid de tl' Capacity❑ No. of compartments---- ----- ' Sizep. ,�_Q--__---_.Distance to nearest lot Iine__��-_.__. �} _ " V+� Disposal R Id: Distance from nearest well-IJ11_--.--Distance from foundation- Width of trench-- ------------ --- .P1 =-__- Length of each line--- -Q--- ---- Number oz lines---.__ -. ---- /!- j Type of filter material.- -- . Depth of filter material_../_ -----------Total length--_-._C�1- ------------ • ' t Seepage P Distance to neares well-/_La_-..--------Distance from fou dation_tG-_�-----•--.Dista �e to nearest lot line-- _-----.-- ,,p ,Size: Diameter --Depth------ ?o--------------- �1 ❑ Number of pits-.-------Lining matersal__0--% - � : - Distance from nearest well-----------------Distance #rom foundation--------------------Lining material------------_-.---------.------_-----. Cesspool: ---.-Liquid Capacity ----gals- O ❑ q P Y Size: Diameter------ --------- --------- --------Depth_---------------•----•-------- ------- -- r Privy: Distance from. nearest well-__-_---_---�-----------------------------------Distance from nearest building------------------------------------------ ine ----------'------ --------- --•---------•-----___. Distanc%fo nearest lot line.--_--------------------- ---•------•--------- Remodeling acid/or repairing (clescribe):------ ---- _ to r= -" ------ - - --- . --------------------- •-----------------------------• ---------------------------- I I -------------------------•------ ' = --etch certify that I have.prepared -------------------- --------------------- prepared this application and that a work will:.be done in accordance with San Joaquin County ordinances, State ws, anderuleind regulations of the San Joaquin.Loca "Health District. . ---(Own d or ntractorj 6 _ - '- ( ! (Signed)_. t - - - --------------------- (Ti+le -------------------------- By=-------- --------•------- --- _ (Plot plan, showing size o lot,. location of system in relation to wells, buildings, etc., can be laced on reverse side). H FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - DATE / ----- iDATE----------------------------------------------------------- REVIEWEDBY------------------------------------- --------- DATE--------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------ Alterations and/or recommendations:----------------------------------- -------------- ----------------------------------------- ---------------------- -- --------------------------------- ------------------------------------------ ------ -------------------------------------------- FINAL INSPECTION BY:..---- ----'_�� ^.-- ---------------- -------------- Date-- ------ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT � 814 North "C" Street 300 West Oak Street 132 Sycamore Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y. ES-9--2M 10-52 Revised W-2100