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APPLICATION FOR SANITATION PERMIT Permit No. _41K_ (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. O JOB ADDRESS AND OCATION-------- - p _-_____ ----- t= ---------------•----- 7 Owner's Name-- `' �./. - - -------- - --- ------ ------------- Phone------------------------------------ ------- ----- - -------------- Address.. ' -- Gontractar's Name----- -•_h ,_----• ___-- Phone---- ---- -- ❑ ❑ Other Installation will serve: Residence ❑ Apartment House Commercial Trailer ❑ ❑ ' ` Court Motel Number of living units: -------- Number of bedrooms ------_ Number of baths -------- Lot size -__-_ _ _ 1-► Water Supply: Public system )( Community system ❑ Private ❑ Depth to Water Table -------- ft. � ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: Q_ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--!�---- ----Dista a from founa'afion-----1_Q--------.Material_-----_bd !- _ No. of compartments Size-- -X_, Liquid depth �� Capacity �'��* Disposal Field: Distance from.nearest we!I__-- ---_ Distance from foundation_----ZP----__-Distance to nearest lot lie---- r___ Number of fines------------- -- g ��__ _ _-----Width o€ trench-__----cam`'_ ---,----,- . 1------i� ----_--Length of each line--___-- --- -- Type of filter material-)4-�_-_'-�- - Depth of filter material-----_l�__ .__---Total length---------- --- ----------- Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest lot line-----_-------__- -40 Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------------------------_- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------_-------__---- ❑ Size: Diameter---------------- --------------------Depth----------------------------------------------------Liquid Capacity----------------- �, . .�,.�,,,. sem- ----------gals. I Privy:' "pistance from nearest well _____ ___________ ______ Distance from nearest buildin❑ Distance to nearest lot line---- g --•----------------------------- -----------------------Remodeling and/or repairing (describe):---------------IV----------_- ----- --------------------------•----------------------------------------------------------------------------------•------•-•----------------------------------------•------------------------------------------------ I hereby certify that l 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)-- / --------- - -------------------------------------- -------------------------------------------------------------------(Owner and/or Contractor) BYl - ------------------------------------------------------------------------- -----(Tit (Pl of 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 1 / } ----------------=------------------------------- DATE REVIEWEDBY---------------------------------------- ------ ---------- DATE_ -------.- --------- DIN PERMIT ISSUED------------- -------------- - -- - ---------------- ---=----.- DATE.----- - ----------- -------------- - - - --------------------------------- ---------------------- A aerations and/or recommendations:---------------------------- -----------•-------------- -------------------------------------------------- ------ ---- j -------------------------------------- t ------------------------------------------------------- - 4 FINAL INSPECTION BY: __--------- Date--/ f�-_.'r.. ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 a