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APPLICATION FOR SANITATION PERMIT Permit No. (Coniplete in Duplicated Date Issued _l_____ Applica-ion is hereby made to the San-Joaquin Local Health District for a permit to cons�rt and i stf all thetvork herein described. This application is made in compliance with County Ordinance No. 549. ` i.r•�164 � J �j� flQ,O LD JOS ADDRESS AN,LOCATION Owner's Name----- -------------------------- Phone------------------------------------ XTI Address. --------r`•- ---� - --------------•------------------- �, { Contractor's Name--------.—_ ---. ------------------ � --------------- ----•---------------------:------------------ Phone_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: � Number of bedrooms ----_�, Number of baths_-/_._ Lot size Water Supply: Public system ❑ Community system ❑ Private .0\, Depthwto Water.Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam.❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [�' New Construction: Yes ❑ No,EU TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,public sewer is available within 200 feet.) t. Septic ank: Distance from nearest well_________________Distance from foundation._.tr-------------.Material----------------------------------- ------------- No. of compartments-------- ----------- ` Size-------=------------------- Liquid depth__------- - ------------.Capacity----------------------- t'� - Disposal Fi Id: Distance from nearest well."AQ d_�t_Distance from foundation_._ .v-�... istante to nearest lot line---g........... ® Number"of lines___________!I__________________�_,,�� Length of each line_._.__.D_-._ ..�_ ._.Width of trench_. _____._______.____ Type of filter material_--S l 3 _z%f _Depth of filter material------ ....____.._Total length___.____c _Q___________________________ Pit: Distance to nearest wel!-----------......:....Distance from foundation....................Distance to nearest lot line----------------- El Number of pits------------------r--Lining material---.-.----------------.Size: Diameter---.--------------.----Depth------.----------•--------------- Cesspool: Distance from nearest well--------------------Distance from foundation-_.____--- Lining material-------------------_________________- .�. ❑ Size: Diameter------------------------------ -------Depth--------------------------------- -r_-- --------Liqid Capacity_--------------------------gals. Privy: Distance from nearest well __.._' -___..___. F_______________________Distance from nearest building_----_----.__.._________________."___.___. ❑ Distance to nearest lot line ----------------•--- -------- ---------------------------------------------------------------------------------------- Remodeling and/or rep firing (describe]:----- -------------------------------------------------------------------' ------ ------- 4 -- - -�° d - -------- 0 ----------------- - �} F-------- -------- --'A- - --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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) 040_�e__-c.. __.Q_�__ ------------ ------------------------------------------- Owner and/or Contractor By:-------------------------------- ............-----------------------------------------------------------------------=-------(Title)--------------------------------------------- -------------------- (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--------------- ------------- ------- t--------------DATE_. .-------.....---------- -•- REVIEWED BY-------------------------- ------------------------------------ DATE_-----�- BUILDING PERMIT ISSUED--------------------------- ------""------------- /•_I/f.•�� .L- DATE d J Alterations and/or recommendations:-------------------------__ J� ---------- - ' _r ^� -----.- -------?-- ------ ---------- ----------- -- ---------- 7 .e - °''�„'-. '" ,,_ " -------"-""" �. - --- ------------- •..... ----------------------------------- FINAL INSPECTION BY:: - - - ------ Date-----------------------------------7----------------------------------- SAN ---- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West flak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California . 4 ESi�--•9 145446 ATWOpp - '"