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APPLICATION FOR SANITATION PERMIT Permit No. ...4-. '- .. (Complete in Duplicate) •� Date Issued _____ __rL.c;Z Applica*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. // ----------------------------------------•------------------------ JOB ADDRESS AND LOCATION__.._ �{O � ------ -------- _ - -------- ------ Owner's Name __ _ p2 Phone ' - ------ -------•--------------- --------...-----------------------------•-----•------------•-•---------------------'-/--------------- �l1t�t - Contractor's Name-------------•--------•---•- - ----------------------•----• -------------•---------.----------------- Installa+ion will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/___ Number of bedrooms __ ___- Number of baths -_ _.___ of size ____-_____ -- Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table ' ft. r Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑° Sandy Loam El Clay Loam 171 Clay [3 Adobe B--HardpanE] Previous Application Made: Yes ❑ ;.No R<New Construction: Yes ❑ No t[�� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ank: Di 4Py stance from nearest well-_;-_________ Distance from foundation--------------------Material-___________-__.---------------------------------- / No. of compartments_......-- - Size---------------------------- --Liquid depth--------- ..-------------Capacity-_ i p Meld: Distance from nearest well________________ Distance from'foundation____-_____--_.____.Distance to nearest lot line__.._________..__ �5 � Number of lines---------------- - -----------------Length of each line---------- ------------------Width of trench Type of filter material-------------------------Depth of filter material------------------------ length---.------------------------- - ----•-- i ;-Seepage Pit: Distance to nearest well-Naw�_----Distance ff m foundation----lSr._____��tance to nearest l line--s__.-______. l� Number of pits:,-- --------- --Lining material--- Gk------Size: Diameter------------- --------.-Depth----- ---5^-____------------. 1 Cesspool: Distance from nearest well-_______-___..__Distancerfrom foundation___------------_____Lining material______-.____ __-___._____________-__. _ --Depth---------------------------------------------------Liquid Capacity --------------------------gals. ❑ Size: Diameter "N Privy: Distance from nearest well--------------------------------------------------- from nearest building--------------.________-------------------- ❑ Distance to nearest lot line- -----------------------------------------------------------I--------------------- --------------------------------------------------- - Remodeling and/or repairing (describe):__ crc ru "�- - - -------------•--------------------.------------ s --------- ---------------------------------------=------ -------•----- r ----------------------------------------- -------•---------•--------------•-----------------------•-------------••-------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. - ---------------------------------------------- Owner and/or Contractor] r (Signed)---------------- ---------•-- -- -- -- ---- - - -- -------- -- ---- ------------------------------ ------(Title}. (Plot plan, showing size of lot, location of system in rel ion to wells, buildings, etc., can be placed on reverse side). j FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ -- - --------- ---- --- ------------------------ DATE ---------=-------------- BY------=-----=---------------------'------------------- - E-_-------- ---------------=--------------- -------------------DAT ----------------------------------------- REVIEWED . BUILDINGPERMIT ISSUED----------------------------------��` - --------------------------------:------------------ DATE.----------- Alterations and/or recommendations:--------- -----------••------------------------------ {.y ---•---------- r r ------_--------•-------- ; _ -------------------------------------- = - ± � •------•----•----------------•---------•--------------•---------------------=•----------•------ -------------------------------------------------------------------------- --•------ ---- ---------- al- �sP - F1NAL INSPECTION BY:----- _ .- --�-------- 'Date -------�- -•------ ---------••-------- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 340 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5 l—ZM 145446 nTwoon 12-54 1