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APPLICATION FOR SANITATION PERMITi Permit .-. 5-_ 1.... �. (Complete in Duplicate) �f / Date Issued ----- ---------•� epplica4-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is made in compliance with County Ordin nce No. 549. / JOB ADDRESS AND L CATIG `'.__. - --------! -- ---------t-------------------•- ------------ ------------------ -- _ ------ Phone Owner's Nam =---- ------- r -- ------ - r - r ------- .._..r - —~" ' - - `'` ------------------•----------------------- Address fi � - -------- ---------- - -----•-- Contractor's Name---- n _ '--�-reg - --------- -------�/`' °'-` Phone.. Installation will serve: Residence Apartm nt House ❑ Commercial ❑ Trailer ICourt ❑ Motel ❑ Other ❑ Number of living units: __4_--_ Number of bedrooms__-_ Number of baths -1-- Lot size __.RC1_ !. .-_______________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table , ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ Adobeg Hardpan ❑ Previous Application Made: Yes ❑ No CIf New Construction: Yes �6_ No ❑ 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---------- ---------------Size__.---•---------- Liquid depth Capacity DispnaFi e f1d Distance from nearest well____--------------Distance from foundation--------------------Distance to nearest lot line----------------- A. El if# _______________.A❑if# Number of lines-----------------------------------Length of each line------------------------------Width of french.-----------_-------------------.-- 1LC Type offilter material________________________Depth of filter material___.____ g P Total length--------------______ _________________ See a e Pit: Distance to nearest wel!_ ,- "_____--Distance from oundation_ __7. /.Distance to nearest Iodine__._.. __ ANumber of pits------!_____________Lining materia ______Size: DiaAiieter___rg��"____..____Depth------nZ.------- �______ p , Cesspool Distance from nearest well-----------------Distance from foundation-------------------.Lining material__._____..___------_________________- [" ❑ Size: Diameter-------------------------------------Depth---- ----------------------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well--------___--------------------------------------Distance from nearest building---------------------------------_______. ❑ Distance-to nearest lot line----------------------------------------- -----------�------------------------------•--------------------------------------------------------- Remodelingand/,or-repairing desc i e ------ "rte � ---- - -� ---- •._. [rte"-«. ��.�� ,,�._ �- -•---........�j'-------------------------------------------- --------------------------------------------------------------------------------------------------------- --------------------------------- - t hereby certify that I have prepared this applica'fion and that the work will be done in accordance with San Joaquin County ordinances,aSfteaws, nd rules and regulations of the San Joaquin Local Health District. - =----------------- ------- -----------------------------------------------------------------------(Owner and/or Contractor) (Signe, ] SY= �, - - (Title]_- ------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be place on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- ------ DATE ------------------------------------- REVIEWEDBY--------------------------------- DATE--� ------------------------------------------------ BUILDING PERMIT ISSUED -- ------------------------------------------------------------- IDATE._ r Alteration and Ir rreecrom#mendations:_ _ --j-.---- 4- A �•" 1 _ `5='_ tf 's!R?: �rwM a---------1............. ' - -------------------------------------------------------------------------------------------------------------------- Ih t __ �------------------------------------ FINAL-INSPECTION BY:-------- ----------------- --------------------- Y Date------ f -' �------- ------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street b Stockton, California Lodi, California Manteca, California Tracy, California f' cc 0 9k1 P ..-A W_910n