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::APPLICATION FOR SANITATION PERMIT Permit No. ..4�_31 7.. (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. A 6t.1 JOB ADDRESS AND L CATION_____ _____ ___ ___ -- -,/- --------- -------- ----� ----------------- ----------=------------ Owner's Name------ ------------- ---- Phone Address------------•-••--------- -------------- __ _ - -• -- - Contractor's Name------------------------------------------ _____•____________ -- ------ ------- -- ------------------------ -------------- --------------------------- Phone.---••--•------------- ----•- ----- Installation will serve: Residence}} Apartment use [-] Commercial [-] Trailer Court ❑ Motel p Other El Number of living units- _f____ Number of bedrooms __umber of baths __ __ Lot size _____ _ -- --- • -____ ----------•-------- Water Supply: Public system ❑ Conimunity'system-❑ Private Y Depth to Water Table /,0- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeJ Hardpan E]Previous Application Made: Yes E] No New Construction: YesX No E] 1 CIE TYPE OF INSTALLATION AND SPECATIONS: (No septic tank or cesspool permitted if public sew ;s available within 200 feet.) Sept' )Fan Distance from nearest._we4___Z"c� istance fr m ound tign--____f__Q -----.Material-"---- --------- ----- ---- I:xNo. of compartments-------`.`�-------- ---Size----`�`-- - ---�--�_Liquid depth--------A,L-----------Capacity...?&6----- Disp sal Field: Distance from nearest well.../6 ' ---.Distance from foundation-----/_._0 _-_-_Distance to nearest lot liner Number of lines-----�'------------------- Length of each line-----f� ---- _� .Wid#h of trench.--_-_r�--_ _-.__-- -------------- Type of filter material__,i l-__- - __Depth of filter material___.___ .r__TofA length-----------�_ See -------------- page Pit: Distance to nearest well______________________Distance from foundation_________--_.____-_-Distance to nearest lot p -i----------------Lining material-----------------------Size: Diameter---------- -------Depth------------------------------ Cesspool: ----------------------------- I Number of pits-' )est well-----------------Distance from foundation---------.---------Lining material___.----------_____.____._____.---_-_. Cess ool: Distance from nee ❑ Slze: Diameter -----;--- ------- -------- De th ----- -- -- ----Liquid Capacity----------- :gals:-Y--rt p Privy: Distance from nearest weli__ ______ ------ -----------Distance from nearest'building --------- Distance to nearest lot line-------------------------------------------------------- - r , Remodeling and/or repairing (describe):------------------------ I ------------------------ -------------- I 'I•' ----------` ------------------------------------- --- ----------------------------------------------------•-----------•-------------------------•-----------•-----••--------------------•----------------------•--------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done ;n accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. 3 (Signed __ _ � � }�.. ...LX-y-_ _..__ -_- y _ ____(Owner and/or Contractor BY: - ------------------------------------------------------------------------------(Title)-------------------------------------------- ----------------- (Plot plan, showing size of lot, location"f system in relation to wells, buildings, etc., can be placed on reverse side). 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- --------- ----------- ------------ ------------- ---------------•------•---- DATE-------- ----- �"� --- j REVIEWED BY ------------- - -------. DATE------- ! '' BUILDING PERMIT ISSUED---------------------------------- - --------------------- DATE---------+-- - V Alterations and/or recommendaf ions-------____________________ F. -------------------------------------------------------------------:-------------------------------------------------------------------------------------------------------------------------------- -------------------------4 ------- -------------------------------------------------------------------------------------- FINAL INSPECTION BY Date- .0 - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+ree+ 300 West Oak Street 132 Sycamore Street 814 North "C" Stree+ Stockton, California Lodi, California `- Manteca, California Tracy, California B-9-2M r0-52 Revised W-2100