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i APPLICATION FOR SANITATION PERMIT Permit No. .__�._.1-- . (Complete in Duplicafe) 6f�, _ Date Issued 1,� ~ Applica+ion isherebymade 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. s li JOB ADDRESS ANp LOCAT ON_______.__ __/ s � _.______ � --�' - r E, Owner's Name------- • -- _._--• I -- -------------------------------------------- Address Pho Address.......-----•...... = -- ------------------------------------------------------ Contractor's 'Name--------------------------------------------------------------_--------------------------.------ --------------------------------------------- Phone----------------------- •------ Installation will-serve: Residence &--Apartment House .❑ Commercial ❑ Trailer;Court ❑ Motel ❑ Other ❑, Number of living units:.__ Number of bedrooms Number of baths + ____ Lot size _- __ `_. ----------------•-- Water Supply: Public system ec'ommunity system ❑ Private ❑. Depth to Water Table -------- ft, f Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes'❑ No L=1 New Construction: Yes `l❑ No �f TYPE OF INSTALLATION AND SPECIFICATIONS: �p (No septic tank or cesspool permitted if public sewer is availa6le within 200 feet.) I Septic To k: Distance from nearest well------- Distan - foundation-._._--..-.-........Material__._::____ __-_____.._______..---------------- No. _--_-__._No. of compartments------- ------- ----- ize----------------- ----------_'.Liquid depth----------- --a_----`--.-Capacity- ------------ a - Disposal Fie, Distance from nearest we!IA4W_e_Distance fromj.foundation_�-__. _._._.D'istance to nearest lot line_ _:____ ' Number of lines------------l_. Length of each line______-�p--- .-e_.Width oPtrench__---_._�c4f'............. Type or filter material-_- _." __..___-__Depth of filter' material_-- ___. ___ Total length______- ` Seepage Pit: Distance to nearest well ----------_--------Distance from,:foundation-------_____________Distance to nearest lot line_________._____- ❑ Number of pits----------------------Lining material..----------'�'-- -.--.Size: Diameter__.- -----------Depth---------------------------------- W Cesspool: Distance from nearest well_______________ _Distance from foundation.__._-._____._1-.--`� cl:Lming,material#____.,___________.____.:_.__.------- ❑ ` r..°.:_�* Size:,Diamete ,,--------------`_ :Depth'= ;1 -- ----- - Liqu Capacity --------�, -----gals. y — : � Distance from nearest well --- '_----------------- Privy: .;-_.___. Distance from neerest building_____ r---------------------------- El _ _------______ ._____❑ Distance to'nearest lot-line---`- - - ------------------------- Remodeling and/or repairing (describe)_-------------------------� I --------•-•----------•----------- --------- -------------------- ----------- - ---• ------------------------------------- -----------•--•----------- ........... ------- --- •---------- :.....--------------. -------- I ------------------------ -----------------------------•--•-------•--••------------ --•--------------------------------��---------•---------------------�----------• ------------•---------------------------•------------- I hereby certify that I have prepared this application and that the work will be done'in-accordance with San Joaquin-County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) = ------- I----------- ---------------_-----------------------(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 44 !� J APPLICATION ACCEPTED BY------------------- ------- -- --------- ---------------- 4 DATE -:_ REVIEWED BY---- ---------------- ----------.,.------------------------------= :_ DATE - BUILDING PERMIT ISSUED---------------------------------- -------------------------- --`----------------------------• DATE------------------------------------------------- ----------------------- ---------------------- Alterations and/or recommendations:---------------------------------------------------------- --------------------------------••-----.-.-------•---------------------•-------- II' ----------- ---------------------------------------------------I-------------------- --- -------------- ------ ----------•----------------------------------------------•---------.-.-.-------------------------------------------- I -------•------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------ -- FINAL INSPECTION BY:- =� = Date. �_. ` -------- � --••----------------•--- i! 1 .1 SAN JOAQUIN LOCAL HEALTH DISTRICT :s 130 South American Street 300 West Oak Street 1 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California 4 Manteca, California Tracy, California r E5-9-2M /95496 AT WOOP 12-54 �