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APPLICATION FOR SANITATION PERMIT Permit No. --- -- -- ---- - (Complete in Duplicate) Date Issued .... .a-��.� 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.. JOB ADDRESS AND JOCATION /-�- icc+ eet�ecu Owner's Name Phone Address------------------ 1...-..&_ l-- ------ ----- - ------------------ ------- L �%.r ---- ------------------- Phone- lc��--.- Contractor's Name..__ . . '��-'- - Installation will serve: Residence 8' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/--- Number of bedrooms _. 0— h umber of baths ------ Lot size ----��-..xl��------------•--•-------- Water Supply: Public system 9-. Community system ❑ Private ❑ Depth to Water Table 40-0---_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Ea_Hardpan ❑ Previous Application Made: Yes ❑ No JZ_ New Construction: Yes 3,, No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan tante from nearest well_;-..---_----.-Distance from foundation__-_------__ Material-----_----------------------------_--........_. ❑ . of compartments------------- -----------Size--------------------------------Liquid depth--------------------------Capacity-----------•---------•- Disposal Field: -Distance from nearest well-------- ........Distance from foundation--------------------Distance to nearest lot line....___...-_--_. ❑ ber or lines-------------- --------------- ----Length of each line-----------------------.----.-.Width of trench. = T ype of filter material---- ---------------------Depth of filter material ----------------- Total length-----.-.....-_-_-------------___--...._.. Seepage Pit: Distance to nearest well_..._/4,/Q1_-,Z_Distance from foujrdation._,V_'_Q-------Distances o nearest lot line.-_;__-`..0_--- mil _ Number of pits---..,--------------Lining material- Diameter..... ..._--Depth__ -------.---_-_.-- Cesspool: Distance from' nearest well-----------------Distance from foundation--------------------Lining material------------------------ ElSize: Diameter--------------------------------- ----Depth-------------------------------------- ----------._Liquid Capacity-------_-------------------gals. Privy: Distance from nearest well-----------------------------F-----------------.-Distance from nearest building------------------------------------------ ElDistance to nearest lot line---------------------- ------•-- ----------------------=------------------------------------------------------------------ -- Remodelingand/or repairing (describe)---------- -----------------------------------•-•---------------------------------------------•--------------------------••------------------------------ - ----------------------------------------------------•--------------------------------------- ----------------------------------------------------------------------------------------------------------------County I hereby certify tha�ave prepared this application and that the work will be done in accordance with San Joaquin ordinances, State ia�, and rules and regulations of the San Joaquin Local Health District. ------------ -- -----(Owner and/or Contractor) Si nedZ—i ----------------- -- T'itle By� �--�- - -- ---- �t ---------------------{ }----- ----- ------- (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 APPLICATION ACCEPTED BY-------_-------- ------------------- ---------------••----------------------• DATE-------- � �- " : =��,y ------ REVIEWED BY------------------------------- --- ----------------------------------------------------- DATE------------------------------------------------------------ - ------ ----- BUILDING PERMIT ISSUED------------ --•-_--------- ----------------------- -------- ------------------------------------- DATE---------------------------------------------------- Alterations and/or recommendations:----- -------------- - - ------------------- ------- ----------------- -------- ------------ - x S - --- ----- - ------------------------- - ---- -------- -----------------•----------------•------------------------------ --- --------------- -- -------------- ------------------ ----------------------------- ....... a --- FINALINSPECTION BY--------- ---------------•--------------- - •------ ----- Date-. ------------------------------ ------------ --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oal Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California �+ E5-9-2M 145446 ATW[10O 12.54