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Or APPLICATION POR SANITATION PERMIT Permit No. _ . - Com lete in Duplicate) ( A Date Issued __-- � � -- Appliceion 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 LOtC�ATION___ //-�-�-.__ P_:! --- ----------------- Owner's Name._..- 'T_t--Y_� " --------- Address -- --------- --- ---- ------ Contractor's Name__._ --�±-- �+.. � / � f►- ► .rf:��..�'a�---- Phone 4- Installation will serve: Residence �Ap rtment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_ ___ Number of bedrooms -__.Number of baths _/-____ Lot size ---- !______________________________•_ 1 Water Supply: Public system ❑ Community system ❑ Private. .J epth to-Water Table X_rl__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel '❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No 6�lew Construction: Yes ❑ No Q 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________________ Distance from foundation--------------------Material____________.__.---__------_________._____-_____. No. of compartments------------------------- Size--------------------------------Liquid dep b------------------------- Capacity----------------------- Disposal Fie4d: Distance from nearest well-.-j---4....Distance from foundation______/ ____.Distance to nearest lot line---- ' -^-- Number of lines------'---- .---- Length of each line----L4?__O---e........Width of french__214_ Type or filter materia l--_L_�---._.- __Depth of filter material___.__ -_______Total length______. _0�._._. Seepage Pit: Distance to nearest well----------------------Distance from foundation____________-_- Distance to nearest lot line----------------- 1771 Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation------------`..__.LiningE material------------------------------------- ❑ Size: Diameter------------------------- Qepth------------- --------------------------------Liquid Capacity--------------------------gals. Privy: Distance from nearest well--_----_'__________________._____--_.________Distance from nearest building_.________.__.____________-____--_-_____. ❑ Distance to nearest lot line------------------- --------------------------------------------------- --------------*-------------------------------------------------------------- Remodeling and/or repairing (describe)--------------------------------------- ---------------------------------------- 7 ------------•---•------------ -• ----------------•---------=---------•------------------------------------------------------------------------------- •-----------------------•-----------------•------------------------ ---------------------------------------------•-----------------------------------------------------------------------------------------------------------------------------------------------_'_------------------------------- is --------------------------------------------------------M�_.,-------------------- ------------------------•--•------------------ -----.---.---:--•------ --------------------------------------------- �. I herebycertifythat I have -repared this a lication and that the work will be done in accordance with San Joaquin Coun t ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------ �- ��'�} ±�».^ r_ ----------------- Qwner_and r Contractor :. . - L� By:--------�'�. �� ' ,a-s... -.'' --------------------------- ------------------------{Title)------ �-�- -----`-`"--` (Plot plan, showing size of lot, location-of-system'in relatio'tii to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------- ----- -------------------------------------------- DATE----`- ----------•------------------------- REVIEWEDBY----------------------------------------- ` y ---------------------------••---- ---------------- DATE-------------�:}_G-------------- •------•-------- BUILDING PERMIT ISSUED-------------- ' = -- -----•------- DATE------------------- ,-._J----------------------------- Alterations and/or recommendations:------•------------------------ -------------------------------------------------------------------------------------• --- ----------------- - ------------------------------------------------------------- --------•----------------------------------------------- ------. -•-- ----•-------- -------- ---------•---------------- --------------•------------------------------------------••-----------------------------•-----------...-....._..... ------------------------------ ----------------- --------------------------------- ----------- --- --------------------- ----------- --•------------•-I----------------------------------------- --------------•------•--------------------------------- FINAL-INSP'ECTION'-BY:----- -------------------------=Y-- Date.--. , .... 4 ._ T SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Was+ Oak Street 132 Sycamore Sireet 814 North "C" Street Stockton, California. Lodi, California Manteca, California Tracy, California FS-4-9AA RA.;...4 \A aeon