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APPLICATION FOR SANITATION PERMIT Permit No. .�jl�_L4__ _ {Complete in Duplicate) a...Q� 1 Date Issued � ------------ Application 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. --- t.tc a -- -------------------------------------------------- ------------------- JOB ADDRESS AND LOCATION---r-� -Al•---- Owner's Name----- 4-----Ax_L_Q -----._. Phone_ ------•--- Address------------------------_------ aan► ------------------ -------------------------- Contractor's Name ----------�-In-`e-------------------•-----------_=----------------------------------------------•---------------------------- Phone---------------------------------- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trai r Court ❑ Motel ❑ Other ❑ Number of living units: .- Number of bedrooms _3--- Number of baths .15—Lot Lot size __113_xtr ________________________ Water Supply: Public system:�K;Community system El Private ❑ Depth to Water Table -------- ft. ,7 Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ k Previous Application Made: Yes ❑ No% New Construction: YesX No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) is Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------.------------NIN-1 No. of compartments------. p�O Size--------------------------------Liquid i depth---------------- --------Capacity.,--------------------- .i ----- Disposal Field: Distance from nearQ�wO__'�1-.._--------Distance from founcl�a�ii n�__.___�--_.__._7,Distance to nearest lot line,r_47_'�..... EA . Number of lines----__----1]. __ __Length of each line-?4-I,- �= + _.Width of trench_____ _ _ ______________ Type of filter materiaL15r?__�a�A_Depth of filter material__.__�_�-__.________Total length------___7_ _ ____________________ it Seepage Pit: Distance to nearest well_.---- ----------------Distance from foundation-------------------.Distance to nearest lot line_-__---___---. ❑ Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth-----------------•--------------- Cesspoo4: Distance from nearest well-----------------Distance from foundation--------------------Lining material__--_---____-------_.___----__----w- 1 ❑ Size: Diamleter---------------------- ---------------Qepth----------------------------------------------------Liquid Capacity------------------------ gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ElDistance to nearest lot line----------------------------------------------------------------------------------------------------------------- ------------ Remodeling and/or repairing {describe)--------------------- --------•----------------------------•-------------------------------------:-._------------------------------------------------------- r --••--•-------•--------------------------------- ---------------------------•-•-•---•-------------------------------------------------------------------------------------- ---------------------------------------------- 4 s ---------------------------- -••-------------------------------------•------------------ ----•-------------------------------------------------------------------------------------------------------- I hereby certify that 1 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)----- -------------------------------------------------------------------------------------------(Owner and/or Contractor) i 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 : 1 APPLICATION ACCEPTED BY----- r > •---------------- DATE-- f ------•------------------- REVIEWEDBY--------------------------" f---------=-----47------------ -------------- --- --------------------- DATE-------------------------------------- ------ BUILDINGPERMIT ISSUED--='------------------------------------------------------------------------------------------------- DATE------------------------------- ---- -• Alterations and/or recommendations:----------- -------------------------------------------------------------------------------------•------•----------------------------•------------------------- qi -------------------•-------------------------------=--------------------------------------------------•------ -=--- -------------------- ------------ ------ -----•------------- ------------------------------- I -----•------------------------------------------=--------------------------------------•---------- ------------------------------------------------------------------------------------------------------------------------ --------------------------- FINAL INSPECTION BY:-----------( ��I ------ - Date----------- --- ----/- ------------ �---------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy, California li E5-9-2M I0.52 Revised W-21001 q} ,z �