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�- APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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. r' JOB ADDRESS%A D T1,XN745-- - ----- - -------------------••-•----------------- ------------ Owner's Name------ --- r Q1 y '' -------------------------- Phone . _= - Address--------&---1...-- -------- --- -------------•-- -- ---------------------------------------------------------------- -----•--•---------------------------------------------------------------- Contractor's Name- -- --------- ---------- ---------------------------------------- ------------------------------------------------------------------- Phone----------••---------------------- -Y Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court E] Mot91 ❑ Oth r E]Number of living units: __!____ Number of bedrooms ---/--- Number 'baths __!____ Lot size /CG Water Supply: Public system El Community system' 'n Private Number Water Table _--__-- ft. - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoVN0,11 Clay Loam E] Clay E] Adobe �ardpan E]Previous Application Made: Yes El No V New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: { A € (No septic tank or cesspool permitted if public sewer 's available within 200 feet# F / ) i i Septic ank: Distance from nearest well___., e f1-02 fou --tion_______:._._____-_.Mate _ No. of compartments-'--_-_.-74--�_-.-.._Si e_ __ .-:_--Liquid fdepth-_. ____ ._._____--Capacity-_-0-0-__-_-, g �--t�crn/ Dis os Field: Distance from nearest w A �istance from foundation _.__.. Distance to nearest lot line_ ` p Number of lines__________ _______ __________---Length of each line---------- - - Width of trench._ r Type of filter materi y epth of filter material----- length----------- --- --.•-________________._. i Seepage Pit: Distance to nearest well--------------:-------Distance from foundation--------------------Distance to nearest lot line----------------- S ❑ Number of pits---------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- 41 Cesspool: Distance from nearest well----------------- from foundation---_----------------Lining material-------------------------------------- . El Size: Diameter------------- ------- --------------.Depth----------------------------- ---------------------Liquid`Capacity--------- gals. m Privy: Distance from nearest well--------------------------.----- ----------------Distance from nearest building._________.__._______-_-.___.-.____-_____. ❑ Distance to nearest lot line----—-----------'-------•---- ------------ ------------•--- ---------------- ------------------------------------•---------------- Remodelingand/or repairing (describe):----------------- ----------------------------=-----------------------------------------------------•---•-------•-••--------••----------------•--------- --------------------------------------------------------------------------------------------------•-••-------•----•--------------------------•---------------------------------------------....--•---------------------------- ------------------------------------------- -------------•--•-------------------------------.... --------------------•----•--------------------•-----------•---------------- -------------------------------------- -- I hereby cer+ify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws; and rules and regulations of the San Joaquin Local Health District. (Signed)_ r,00410" a + -------------------------------------- -- ----- - --------------- ) --------(Owner and/or Contractor By:------ ----------------------------------------------------------- -----(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 i ' APPLICATION ACCEPTED BY- - -___. _ ' - DATE- _-- REVIEWEDBY_ " -- -------- ---------------------------------- ------- DATI=--- '_ BUILDINGPERMIT ISSUED----------------------•------------------------------------------------------------------------------ DATE---- Alterationsand/or recommendations:------------------- ------------------------------------------------------------ -•---------.................................--------•----------- -------------------------------------- ---------------•-----------------------------------------------------•----------------------------- FINAL INSPECTION BY:_'-'-- ------'--------------------• Date.- ------ —- —---------- ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California j E5--9-2M 145446 ATWRno 12-54