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APPLICATION FOR SANITATION PERMIT Permit No. ......74 _�L_ (Complete in Duplicate) 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.r . LS JOB ADDRESS -- AND LOCATION- Y---f-I... - ---------------- --------- -------------------------------------------------- �/ Owner's Name------ ! � -- --- " --•------- ----------------- ----------------------=------------------- Phone------------------------------------ pp '6 .- Address.----. J {, r= �- ------ -- Contractor's Name.----- - .I ---------------------------------------------------------- Phone----- ----------------------------- -4------------------------------------------------- Installation will serve: Residence �Apa.rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units::+__/-_. Number of bedrooms _�^ Number of baths I____ Lot size ....... ---------------_____________ Water Supply: Public system'`�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[P--TTardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes ga"11-o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) oo p Septic Ta -- Distance from nearest well-( �__Distance from foundation__ _--______Mat rid!-----11___________________ No. of corm.partments._,_ "---------------Size---- '_ _'�"_ Liquid depth------- _._..._.______Capacity_ J_ _.___ Disposal Wield: Distance from nearest well _.D.istance from foundation-__. _ .___..Distance to nearest lot li`e__-!_________ Number of lines_____ __ __________________ _ Length of each line----_-----------0------__.Width of trench_._.2 0A,-------------------- Type of filter material___-� .`Depth of filter material_/�'��:.___Total length___.A;L—------------------------ ,; Seepage Pit: Distance to nearest well______ -----------Distance from foundation-------___________b.Distance to nearest lot line___._.____.._---_ ❑ Number of pits.------- --Lining material-----------------------Size: Diameter------------- ---------Depth----------- -------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------ .-.-_ ❑ Size: Diameter---- --------------------------------Depth------------------------------------------- --------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearesr building------------------------------------------ F1Distance to nearest lot line----------------------------------------------------------------------- ------------------------------ -------------------------------------- 11 Remodelinganti/or repairing!(describe)----------------------------------------------------•--•-----------------------------------------------------------------------------------•------------ ----•- ---------------------------------------- '=-------------------------------------------------------------------•------------------------------------------------------------------------------------------------------ I herebycertify that I have prepared this application and that the work will be done in accordance with San Joaquin Count Y P P PP G Yt} .�� ordinances, State laws, and rules and regul tions of the San.Joa Local Health District. J1 3 (Signed)- ------------- {�✓ ��, (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). i! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------ ------------------------------------------------ DATE REVIEWED BY-------------------------!I----------- ------- DATE L ,r / - -- ---- --------- BUILDINGPERMIT ISSUED-- ----------------- ------------- --------------------------------------- DATE---------k. --------•-----•--------------------------------- Alterationsand/or recommendations-- --- ----------------------------------- --------------------------------------------------------•-------•------------•--•---------••-------------------- .1! -•-•---•----------------------------------------------------- ------------------------------------ ' ---------------------------------------- ---- -----! -i p- ---•----------------------------�---•- ---s--------------------f----- ----------------------•----•-•------- --3--------------------•--•---N-----------••-------- ------------------- i - ---------------•--------- ----------------------- - -------- -------- -FINAL INSPECTION BY:._ ----- ----- ----- Date-----------"------ -- ------�------- - i ------------------ ------- SAN - -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Sou#h American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street i Stockton, California Lodi, California Manteca, California Tracy, California ES-9----2M 10-52 Revised W-2100