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v APPLICATION FOR SANITATION PERMIT Permit No.?A� .... (Complete in Duplicate) `� SZ Date Issued App[ica{ion 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. (0-jc3 5,357 'E ' �Q � � � StrJ tis. l� `aJOB ADDRESS AND LOCATION—A/Ae --- --- - ----- - ------ - --------- - Q-------•---•------------ Owner's Name 1,1 5 `s f Q--�-�----------'�-��/-----'---•----------------------- Phone./.�_ 3`�_.'S�l�� _� `-`� 1�R L- ' Address • -5 ----------------------------------------- ...................................... Contractor's Name--- t .! ...... '_Z _C P------------------------------------------------------------------••-----. Phone_/ ----- Installation ---Installation will serve: Residence [j?"'AApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i f Number of living units: --- Number of bedrooms _¢:. Number of baths __;`2r Lot size ______________________W Water Supply: Public system ❑ Community system ❑ Private 2j--Depth to Wafter Tabled=<' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ©--Hardpan ❑ rh Previous Application Made: Yes 0 No New Construction: Yes ®- No ❑ 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__-',1"J-------Distance from foundation-----/__!5�---.__Material__�4'�___.__t�__--------_---.-�___-_____.__. No. of compartments--------_�'y---------------Sizer ---`�'--. ��-•---Liquid depth__.---6-_? ........... Disposal Field: Distance from nearest well-..7 .......Distance from foundation__- !_�-_A--Distance to nearest lot line_________________ Number of lines------------- p-W Length of each line_.f%0__-S�_`__ 5-4.�Vidth of trench--------- __` _`�______________ Type of filter material------ ___.f __Depth of filter material:_____/. "__.._Total length_____ ___________________ Seepage Pit: Distance to nearest well---/ate"7___Distance from foundation__ a_ ...__.D-sstance to nearest lot line__e,?_ �y Number of pits-----,�-----------Lining material---b_f1'C_K--Size: Diameter.__✓-----------Depth-----96...________________ Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material------------------------------------- ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_ _____________________________________Distance from nearest building------------------------------------------ M _____ ___________---_______.___.__.❑ Distance to nearest lot line----------------------------------------------------------------------------.----------------------------------------------.------------------- Remodeling and/or repairing (describe):------/Y- � &-19 �t/rs�---' --------------------------------------------------------------------------------------------------------------------------------------------•-••-------•-------------------------------------------------------------------- -------------- ------------------------------•----------------------•-------------•---- ----------------------•---------------•-•-•---------------------------------------------------------I ti I hereby certify that I 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, c (Oer - ----- - ------- and/or Contractor) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ----•------------------ ----- --- --------------------------------------------------- DATE REVIEWEDBY--------------------------------- -- ---------------------- --- ------ ---------------------------------------------------- DATE ... -------------------------- BUILDINGPERMIT ISSUED------------------------------------ --------------------------- ---------------------------- DATE... --- ---•• -- Alterationsand/or recommendations---------------------------- - -------------------------------------------------------------------------- - ------------------------ +: ----------- ---------------- ----- ------------------•---------------------------------------------------------------•-• FINAL INSPECTION BY:------- t.� - ..._ Date--- .!�------~ -! ----------------•--•-_------ 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 E5-9-2M 145445 ATW000 12-54 �I