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APPLICATION FOR SANITATION PERMIT Permit No: ---170--0---G-- (Complete in Duplicate) Date Issued c Applica-%n 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 complian#e with County Ordinanc No. 49. JOB ADDRESS AND LOCATION _._ D- 1h --------• ------- --- ------------------ -- ------ ------ i ------------ -------- Pkone-----------------------•------------ Owners Name------------•---`--,---3--�----•- r AddressrA--------------- ----------------------------------------•------y------------------•-----------••----------------•----------- �- • ------ ne_ -Contractor's Name--------------- installation willaerve: Residence A�arfinent House ❑ Commercial ❑ Trailer Court ❑ Motel'❑ Other ❑ _ p E _ Number of living units: __/-_ Number of bedrooms _,/ -- Number of baths __/- Lot size ---1-5-- -------- Water Supply: Public system Community system ❑ Private ❑ Depth to Wa#er+TableJr-d- ft. Character of soil to a depth of 3 feet: Sand ❑ GravePM*t5gdy Laam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ Previous Application Made: Yes []i No New Construction: Yes ❑ No19 # yf TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 240 feet.) ' ___________Distance fromfoundation--------------------Material______.___-___. _ .___._..-_________________._ Se Tank: Distance from nearest well__ __ ------------------------- Capacity---------- -----------:- No. of compartments'---------_._..- - Size -------- ue . Di osal Fi d: Distance from nearest well_________________Distance from foundation_______---____.-___.Distance to nearest lot line_-_.__.__...___ Number lines- - Length of each line-----------=---------t---- Width of trench---------.--------------------•--- Type of filter material------------------------Depth of filter material--------------- -----..Total length------------------------------------ot ------ Seepage Pit: Distance to nearest w/elilc�------ Distan �ndaZe n --/10-er__..-30.... -to Dearest pth lo� -------------------- ------- e_____--- Size: - Humber of pits-------/--_ g. mat Cesspool: Distance from nearest well-----------------Distance from foundation-__.______-_._____.Lining material_________-_-.___-_________.-_ ----De Depth ------------------- - -- ----------Liquid Capacity- ------------------------gals. ❑ Size: Diameter--------------------------- ------ p - - - - ---- - Priv Distance From nearest well_:.___._-...___.._-_____.----------------------Distance from nearest building______________________________________ y: + --- ❑ crest lot line----- -- --------------------------------------------------------------- --------- } Distance one 1. Remodeling and/or repairing (describe)-------•---------------- �------•---------------I-•----------- --------•----------•----- s ---------------- -= = --------- I hereby certify that I have prepatreed uthis application en J that th" workal HealltheDistr ctn accordance with San Joaquin County ordinances, St aws, and rules a d g r (Signe =' " /3" Owner and/or Contractor) ---------------------- ------------------ .- -' -------------- ------ By.. [ • ) (Plat plan, showing size of lot, location of system in r anon to wells, buildings, etc., can be placed an reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- --------- ---- DATE.----->-- ------------------------------------------------ � DATE___ _ .�__ REVIEWED BY------------------------------ - -------------- DATE--------- --- BUILDING PERMIT ISSUED---------- -•---------- - _ ----------------- Alterations and/or recommen ations:______................. -------------------------------------------------------------- r --- - f .. _ � �.. _ 1 •--------------- --•-• =---- --------------------- -V ---- ---- ------- ---------------- ----- ----------------- - ----------- - --- FINAL INSPECTION BY:_..Olel- � ------------------- Date----- 1... -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT Soo West oak Street 132 Sycamore Street 814 North "C" Street 130 SoutF American Street Tree California Stockton, California Lodi, California Manteca, California y� E.9-9 145446 ATWDOD