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f rii' LICATION FOR SANITATION PEr-17 Permit No. ... y (Complete in Duplicate) } Date Issued --- Applica�ion is hereby made to the San Joaquin Locaf Health Districtfo This application is made in compliance with County Ordinance No. 549r a permit to construct and install the work herein described. JOB ADDRESS AND �OCATI�ON.. r C "j - Owner's Name s Name (1 -'. f _.l� -,_ I Phonef � �' -----. Address..---------------------- .` ' ------...- r Contractor's Name.....-_...��-.t�. , ------- ----------- Phone_.-.. --1-V----- -�r_>_��1- a Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units; ---I.... Number of bedrooms ---Y Number of baths -/-__ Lo} size ..-- --------------------r t�Ea Water Supply: Public system ❑ Community system E] private [0rDepth to Water Table -__..__ ft. Character of soil to a depth of 3 feet: Sand L] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe®'Hardpan ❑ Previous Application Made: Yes No ' ❑ ❑r" New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se Tank: Distance from nearest well-----------------Distance from foundation--------.-----_...-.Material-------------------------------- No. of compartments ' --- ---"--"-- �_..... ------------Size------------------ -------------Liquid depth ----....._ -- ---- -----Capacity----- - ----------------- Dws osal Field-------- Distance from nearest well__---------------Distance from foundation...__....__.....-..Distance to nearest lot line.-_.-.__..-_.... {� �lumbor of lines ere - - ------length of each line--------- -------- ----------Width of trench-------- Type of filter material.__ .._._ Depth of filter material.......... ...... .. - - .Total hngth------------•---------- --- ----------•-- Seepage Pit---- Distance to nearest w ll ----------Distanc fRro n foundation_-.._ _ -___ Distance to nearest lot line._..... !� .+'f rr l , ` r f Number of pits... ,= dining material-t- --_.-Size:,1�1 ( .-Size: Diameter..r,_F�f - Depth.-,-4. .. A------------------ Cesspool: Distance from nearest well-----------------Distance from foundation.___..__-...-__-- Lining material._-....--_-_..- ..-_....- °r ❑ Size. Diameter---------------------- -------- Depth -------Liquid Capacity---------------------- -----gals. Privy: Distance from nearest vrell_-------------------- --------------------- Distance from nearest building ❑ Distance to nearest lot line................... .. ---------------------------------- Remodeling and/or repairing {describe)------------------------------------------------------- ------ --------------•-------------- --------------------- a --------------------------- ---------------------------------------•-•----------------- --------------------- w- ---------------------------------------------q---------- -----•---------------------------------------------------------------------------- hereby certify that ! ave prepT., d this application and that the work will be done in accordance with San Joaquin County I ordinances,-�5tate law , and rules andulations of'the San Jaa uin Local Health District. (Signed)---- - -- �-. ' =_------- ,. . �i --------f -------- BY: --- -------- ' ., �-e``= ='' ' %"- '"r= {Title).3 -/- 7 a/tea rContract i or (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i /Z f `" FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --- ----------- DATE---------- REVIEWED BY ---------------------------- ---------- --"------------ ' E -------------------- DATE BUILDING PERMIT ISSUED---------------------- -------- -----------•--- ----.- DATE---- --------------------- A aerations and/or recommendations:_................... -- ------ � ................... ---------------- ---- fN-- FINAL INSPECTION BY:--- . -f` - ---------- Date... f 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 rs-9-2M 145446 ATwUDD 12-54