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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicatel 4 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. 'JOB ADDRESS AND O ATION,-_";I__7 -------- •------=------------------------------------------------------- Owner's Name--------------• . ------ Phone-•-- --•---- Address __-7..__s ----•--- -----------------------------------------------•-•------------------------------•-•--------•-------------------------------- ---------- •------ - Contractor's Name------- _ -- ------ ------ ---- - Phone-- --------•--------•-------------- Installation will serve: Residence Apartment House ❑ Commercial [ITrailer Court E3Motel C] other ❑ Number of living units: .../--- Number of bedrooms _1/ --- Number of baths _1____ Lot size Water Supply: Public system '" Community Y s ystem [IPrivate ElDepth to Water Table ____"___ ft. __ __ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay El Adobe Hardpan [] Previous Application Made: Yes ❑ No 6 New Construction: Yes 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_N4/Y_Wistance from foundation___f 0__e_" n Ma#erial_-I.FCrl�L�a,t ,a No, of compartments.... -------------Size---�-)C_�--- - )C_ :___Liquid depth------_ __ Ca ad y Disposal Field: Distance from nearest well_N_P_*/_(-Distance from foundation____-/jo"---"-_-.Distance to nearest IV line____ Number of lines----------- _----------____......Oengt� ofeach line___._ -/ , f � -------Width of trench---- -- Type of filter materialii5_e. fly filter material___._j_$ ------------ length----L_ -6 --------------------- Seepage Pit: Distance to nearest well__--------------------Distance' from foundation-------------------Distance to nearest lot line_.. 171Number of pits---------------_------Lining materiaLs_--------------------_ Size: Diameter------ Depth ___________"__ Cesspool: Distance from nearest well---- Distance from -------------- foundation--------------------Lining material ❑ Size: Diameter--------- �V ----------- ----------- Depth--- -------•------�----- ------•---------- ---- ----------- -Liquid Capacity----------------------------gals. ❑ Distance to nearest lot fine--------- ------------------------------------------ Privy: Distance from nearest well_._-___ ______________________Distance from nearest building ---------------------•-------------- -- --------------------------------------- �f ------------------------- Remodeling and/or repairing (describe)------- ------------------------------ r C- I_�i.r ------------------- t ---•--------------------------------------------------------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 laws, and rules and regulations of the San Joaquin Local Health District- (Signed)._te 44,0L/---K - ----------------------------- -- --------- --------------------------------------------------------------- --------(Owner and/or Contractor) By:----------------------------------------------I------------------------------ --- Tale _ (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----------- --------- ------- _--__-----._ DAT -- ---_-.-"_-- REVIEWED BY � --------= --- ---- --------------------- - ------- ---------- -------------------------- DATE----- - -- � _ BUILDING PERMIT ISSUED_,------------- ( -------------•----------------------- DATE----- ---- Alterations and/or recommendations:--- -- ------- -- ------------------- -- -- •--�-------•----••-----.- -----------•-- -------- ------------------••-------------------------------- , FINAL INSPECTION BY---------- ---- I" -------------------- 3- -9 — ----------- r Date...------ - -- -----------------:-o------- - ------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT } F ti 130 South American Street t 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOP 12-54 f ,� lJ