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APPLICATION FOR SANITATION PERMIT Permit No. .__ .. d_7. i (Complete in Duplicate) Date Issued .___. 0 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. 544. JOB ADDRESS AND LOCATiON_____F_{f 6 ._ `s_4_ __ _ _ _____________________ / j f --------- -- - ------- -------••--------•-•---------------------------------------------------- Owner's Name__e° _ a/ - •--- -401A -------------- -----------•--- ----- - ---------------- Phone------------------------------------ Address---------------------- Contractor's Name--- --------------•__ ------------ Phon _.. L -- Installation will serve: Residence A Apar#ment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __Number of bedrooms -3. Number of baths -2-r---- Lot size ---Zo,.-6---- �_.._J-.,' - -A'--------------- Water Supply: Public system t—Q mmunity system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No ZT-__N.ew Construction: Yes ❑ No Hp-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Sept• an - Distance from nearest well_________________Distance from foundation_-----------------Material __-_----__-.._.__-________________.__----__-__. j No. of compartments---- ---Size--------------- ---------------Liquid depth--------------------------Capacity--•--- ---------------- Disposal Field: Distance from nearest we€le,7%*%.(--.-Distance from foundation----/,0__r...Distance to nearest lot Iii�__/Q___�_. _ Number of lines--------- _ . �j Length of each line------ l---_ Width of trench.__'1, -*f_ Type of filter material____Il ------------Depth of filter material____.__� ..____Total length-__-___ _v_______________________. Seepage Pit: Distance to nearest well-r7l _____Distance m fou ation------ .___.Distance to ne ine---�. ------- Number of pits___- -_-.___-_____Lining material_-. x - -r.Size: Diameter. .`-'_____-De -----QSrs - 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--- - ---- ------ --- ------ - ------------------------- Remodeling -----------------------Remodeling and/or repairing (describe]---------- ---------------------------------------•---------------------------------.•------------------------------------------------------------------- ----------•-----------------------•--••-----------------------•------------•--------I-------------------------------------------------------------------------------------------------------•-•------------------------------- ------------------------------------------•------------------------------.----------------------------------------------------------------------.-.--..._.------------------------------------•------------------••----------. ----------------------------------------------------------•-------------------------------------------------•------------------------------------------------------- ------•------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, a d rules and regulations of the San Joaquin Local Health District. (Signed).....- -------- -- - -- ---- --- -----------00-------------------------- ----------------------------------------------------------------------(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------- �- REVIEWEDBY--------------------------- ---------- ------- ------ --- - DATE------------- - BUILDING PERMIT ISSUED---_-_-_------- - -------------- -.----, - DATE------------- � -------------- Alterations and/or recommendations------------------------------ -- --------------------------------------------------------•------•------------•--------- ---�-- ------------------------- ----------- - s ----------------------------- -- " --------------- ------------- FINAL - FINAL INSPECTION BY:- --- - - Date----------/----- V- 3.-------C).--J--------------------------- 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 ES-9-2M 145446 ATWOOO 12-54