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r1 APPLICATION FOR SANITATION PERMIT Permit No. ---------------- (Complete in Duplicate) 0SS�a _ 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 No. 549. JOB ADDRESS AND LOCATION....... &&001 Ore. Owners Name___.______ ------- - ----• ----.----- -- t. ---- Phone------------------------ ------ -------- --- ------_------- Address....--------------------- ---- i • - --- •----- .-- --------------------- _ _ /..... Phone-Phone_✓ -",�-�--- -- Contractor's Name_____________ ___---*0 • ��I Installation will serve: Residence Apartment House [] Commercial ❑ Trailer Court ❑ Motel [I Other [INumber of living units: -------- Number of bedrooms _� --A _ Number of baths •--- Lot.size - -=- -�i_-.f#---f--/---�'' ----�I--------------- Water Supply: Public system ommunity system ❑ Private [:1 Depth to Water Table _ ft. Character of soil to a depth of 3 feet: - Sand ❑ Gravel ❑ Sandy Lo;_�_Or, -Loam ❑ Clay E] Adobe Hardpan El Previous Application Made: Yes [I No ❑ New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation------_______._____Material____________-_-__________________________-___. ' No. of compartments------ ------------------- ve_-.----------------------------Liquid dents-------------------------Capacity-----------/--- 1 stance from foundatio r --Distance to nearest lot l�e_!__61_____. Disposal Fisl •- Distance from nearest well../.��_Yl . _ �• / Vyidth of trench.____ _ ____/-Length of each line------ '"-•-- � /---•---------- Number of.lines---, -`---- - - - g Type of filter material -_ - _ pth of filter material___.- -_ _--— length------- ----- ------------------- • •. ...___.Dig anc pA. earest lot 'n e_,C�Gl______ Seepage Pit' Distance-to neare t well'_ 1 --- --Distance fr fou dation_..__ __ De }n („ Number of pits --------Lining material- FS¢e: Diameter :p '1 Cesspool: Distance from nearest well------------------Distance from foundation____________________Lining material___________-____________,__________. p Size: Diameter- �-�-----�- DepthLiquid Capaci#y----------------------------gals. Q ❑ ---------- --'-�-�--- - , Privy: Distance from neare t well a -)----------------------------------- -Distance from neares} building----------------------------------------- A—� ❑ Distance to nearest lot line ._____---__ _ -------- i Remodeling and/or repairing (describe):_..-____.__--- ------ - -� -• - - _. 4tr ----- - ------- 1 --- ---=---- x' - --- --•_---• ---•------- ---------- - ------- --- - ------ -------------------•-- ---- --•---- k I hereby certify that I have prepared tis application and that the work wil a done in accordance with San Joaquin County ordinances; State laWaddegu,4 ules and"rt'o of the San Joaquin Local Health Dist ict. � rand/o antriat+or ) (Signed)--dn----- . - -.�. ' ) - --- --- ------------ By:----------------------•-------------•------------ ----------------- --------- -------------------•---------------- (Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I r FOR DEPARTMENT USE ONLY r DATE-- ----------------------------------- APPLICATIONACCEPTED BY------------- --- - ----------------------------------------------------- y REVIEWED BY-------------------------------- ---- -- ------- -------------------------•----=-------- DATE- BUILDING PERMIT ISSUED---------------- -------•---- ----------------------- -- DATE----------------- •--•-`��---- ----------------------- ---•---------------=------- -- Alterations and/or recommendations___________________ �--------------------------------------------------------------- --- ••-•--- ••--- ._..... --------------------- - --------- --------------------------------------- FINAL INSPECTION BY— --e:�;----------------------- 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 cc a-9TA Rav7sad W-2100