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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) /j.. ....X/Z Date Issued ------ A �plica4ion is hereby made to the' San Joaquin Local Health District for 6 permit to construct and install the work herein described This application is made in compliance with County Ordinance No. 549. Af-3- O&C-67 JO ---- --- ----- B ADDRESS AND L,PATI Own ----------------- ------------ - -- ------------------------------ ----- ---- P -------------------------------- er s Name------- -4 7 Address------ .......!------ 0 10 ------------------------------------------------------------------------ -------------- ip"d "W: ---------- ---------- -------------------------------- Phone-,14o- Contractor Name-------;� Installation will serve: Residence Apartment House ❑ Commercial [] Trailer Court E] Moteljo Other 0 Number of living units: /-.____ Number of bedrooms.,-A-. Number of baths --/_ Lot size ---- ------------------ Water Supply: Public system *; Community system [I Pri'vate F Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand E] Gravel [:) Sandy Loam El Clay Loam E] Clay F1 AdobalK Hardpan ❑ Previous Application Made: Yes [] No E] New Construction: Yes 0- No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wiflhin,100 feet.) Septic Tank: Distance from nearest well�Distance from foundation---A --------Material---- --------- No'. of compartments__..=-.-----_..__Size_. Liquid depth._____.-_______---------Capacity__.__ 'd" ___ Disposal apacity----- Disposal Field. Distance from nearest welVqS/eex4)11sfance from foundation-VK-40---------Distance fo nearest lot line-t-040-/- .. Width of trench----- --—:;�-?-r............... Number of lines___.___:-_ - ----- --Length of each line__:_ /9 Type of filter material- .,O�------��4-0-.-Depth of filter materia-l----. Total length------ --Z-------------------- Seepage Pit: Distance to nearest Wei l-Al"471AE,0 istance km foundation-4te--------Distance to nearest lot line--C6--------- Number of pits....../---------------Lining materi4AR-.-o0,q4,4iVz9-. Diameter__.._101-S, Depfk-n;;?-��-/---------------- U --- cesspool: Distance from nearest well-----------------Distance from foundationlr- --- - ---------Lining material------------------------------------- 0 Size. Diameter------------------- -----------------Depth---------------- -----------------------------------Liquid Capacity- ------------•------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------------1��, ❑ Distance to nearest lot line-------- ----------------------------------------------------------------------------------- -------------------------------------------------- Remodelingand/or repairing (describe):----------------;-----------1-------------•-----•------------:----------•--••-------•-----------------------•---------------•------•----------------•---- ------------------------------------------------------ ----------------------------------------------------------- ---------------------------------- -------- --------------------------------------------------- N --------------- - -------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- ---------------------------------------------------------------------------•--------------------------------•------------------------•--.---•--------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Sari Joaquin County ordinances, State 1, and rples and regulations of the San Joaquin Local Health District. (Signed) --------------------------------------------------L----------------(Owner and/or Contractor) - -- ----- ------- ---- --- . (Title) ------ ------- ------------------------------------- By: - -- ---- (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 17--%- APPLICATION ACCEPTED BY-------------------- Z�- --------- ------------------------------------------- DATE 1�- -- -----------e15-------------------------- ----------------- REVIEWED BY-------------=------------------------------------ ----- ------- ----------------------....-•- ------ DATE---------------- -- -1- ------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------- - ------------------------------------------------------•-• DATE----------------------- ---------------------------- Alterations and/or recommendations:________________________ -- ----------------------------------------------------------------------------------- fi ---•^r-- ---- -------- --------------------------------------------------------:---------------- ------ ------ - -!W------------------ -------------- ------ --- -- - -1 --I- -- -------A--.. -6-� ------- -------- ------------------------------------•--------------------- --------------- .................. ---- --------I i --------------------------------- ------------------------------------------------------------ --------------- ------------------------------------------------------ ------------------------------- --------------- ---------------------- - --- -------------------------------------- ----- ----------------------- ------------- --- ----------------------------------------------------------------------------------------- FINAL INSPECTION BY:-------K's--------------------------- --- ...... Date-_---- - `- ----------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sicarnore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 145446 A7WOOD