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1R1 APPLICATION FOR SANITATION PERMIT Permit No. __G.. O....... (Complete in Duplicate) !i I Date Issued Applical,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-------- -_#.7-------------�----------- --------- Owner's Name — ----_ev--------- ----------------------- ---------------------------------------- Phone-------------------------------- Address------ --------------------------Address------ ------- •n............. - ------------------------------------------------------------------------------------------------------------------------- Contractor's Name------- v-•-- ----------------- - ------------•--- -------------------------------------------- Phone----------------------------------- Installation will serve: Residence A Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �� x /a Number of living units: _(.____ Number of bedrooms __ -Number of baths - ___ Lot size ______ _________--------------------__-_________.__________ Water Supply: Public system [4 Community system ❑ Private ❑ Depth to Water Table _,l ft. f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [S( Hardpan ❑ Previous Application Made: Yes E] No PL New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: \ (No septic tank or cesspool permitted if public sewer is available within 200 fee+.) t Septic Tank: istance from nearest well__,��flistance from foundation--------------------Material________.__.________________________________. ❑ ao. of compartments - - ------------ Size---------------------------- ---Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well.../V+.-,-Distance from foundation____ ______.Distance to nearest lot linel_.e2i_1____ Number of lines-----------1----- -- _ --- Length of each line------- v�-------------Width oftrench-_----� ------------------- Type of filter material._. k_J&-kDepth of filter material__.1�---__.___.Total length------- ____________________ r Seepage Pit: Distance to nearest well--__Z �D istancer from foyndation____4Q_.._.___.Distance to nearest lot line-----<.4'_..: ; Number of its_______ ____________Linin material___ -._.___.______.Size: Qiameter.___3 `01--.---_-Depth M p 9 �"`�{ p A -- -------------- Cesspool: Distance from nearest well-----------------Distance from foundation.,.---------------- Lining material------------------------------------- F1 Size: Diameter-------------------------------------Depth---------------------------------------- ------Liquid Capacity----------------------------gals. \ V - Privy: Distance from nearest well------------------------------------------------ -Distance from nearest building------------------------_---__-------- I ❑ Distance to nearest lot line---------------------------. r Remodelingand/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 ordinances, Sta+ ws, and rules and regulations of the San Joaquin Local Health District. (Signed) _ /l 'f ------ ll'�-------------- ---- --------------------------------------------------------- --------(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 APPLICATION ACCEPTED BY---------- ------ --------------------------------- DATE------------->- -- f -.-Vr5�-------------- REVIEWEDBY--------------------------------------- --------- --- ------------ ---------------------------- --------------------------.- DATE---------------------------------------------------------- BUILDINGPERMIT ISSUED.-..--------•------------ --------- --- ------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------------------------- -----------------------------------------------•--------------------------------------------------------------- ----------------------------------------- ------•------------------- ------------------------------------------------------------------------�---------------------------------------------------------------- ------------------------------------------------------------- ---------- -- ---------------------• -------- -------------------------------------------------------------------------------------------------------------- ---------------- ------------------------------------ ------------------- ------------------------------- ----•------------- ----------------- ---------------------------------------- •---------- ------ --------------------------------------------- -------------------------------------------------------------- FINAL INSPECTION BY:----------- �_� r!1r1 Date---------- b--------- ------------------------------------------------ v SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfraet Stockton, California Lodi, California Manteca, California Tracy, California ES J-2M 145446 ATWOD� 52-54 - - -