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4 /0 e0l", RMIT2—APPLICA ION FOR SANITATION Permit ------7.... .------- (Complete in Duplicate) Date Issued ------------------- gA plica-�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. 1 1 JOB ADDRESS AND,40C ATIO N___ ---- -----0- A. A9L - ---—----- ------- Owner's Name- --------- --------- ---------- ------------- ------------------------------ - ----------------------------------------- Phone----------------------------------- Address-------- .... -------- -------- --- ------------------ ---------t------ -------------------------------------------------------------- Contractor's Name---------------- - -- --- - -------------------------------------------- Phone-------------------------- Installation will serve: Residence E] Apartment House 0 Commercial 0 Trailer Court Lj Motel [-] Other $0 � Number of living units: -------- Number of bedrooms --- ---- Number of baths -------- Lot size ------- ------------- Water Supply; Public system El Community system [] Private EX Depth to Water Table ..5-. ft. Character of soil to a depth of 3 feet: Sand F] Gravel F] Sandy Loam 0 Clay Loam Ej Clay El Adobe[A Hardpan ❑ Previous Application Made- Yes E] No R New Construction: Yes A No F1 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is.avaitable within 200 feet.) Septic Tank: Distance from nearest well-- -7 ------ "fa ---- ,---Liquid efr-,—M-_f",maf ion-----i ---Mgte/iai--------tl#-% ---- -- ---- ---- de ------- Capacity--- CK No. of compartments---2------------------- '-- L Disposal Field: Distance from nearesi:=N-1/0----- Distance from foundation----- -- ..... i fAnce to nearest _�ine---lzl:�r.. Number of lines-- - -- ----------Length of each i h of ------------- Type of filter mate _Depth of filter materia ------- otal Iengfh__ ..12_.�------------- ------------ �c Seepage Pit: Distance to nearest well________________-----Distance from foundation_________._____. _.Distance to nearest o ine----------------- 0 Number of pits----------------------Lining material--------.--------------Size: Diameter-----._-----------.----Depth.-- -- ------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation....____...___.___ Lining material_----__..._.___..____________.______ ❑ aterial------------------------------------- F1 ' Size. Diameter-------- ------------- ---------------Depth------------------- ------------------------:---Y Y__ Capacity:'_._::: ._- uid Capacity - _.-___gA1s-_ Privy: Distance from nearest well_____ __________________________________________Distance from nearest building.-__.____.___.___________________.______. ❑ uilding----------------------------------------- El Distance to nearest lot line- - ------------------------ --------- ---------------------------------------------------------------- -------------------------- 0 ---- Rem eling and/or repairing (describe):..... -- ----------- -------- ---------------------------------------- ---------------- -------------------------------------------------------------------------------- ........... --- ----------------------------------------------------------------------------------------------------9. -------------I---------- ----------------------------------------------------- ------------------------------------ --------------------------I-------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, 9WL*laws and r I s and regul ions of the San Joaquin Local Health District. (Signed)--- T Signed)..... ........z----- ------- --- -------------- - ---------------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:----- ----- ------------ -------------(Tifle)_.-------- --------------------------------------------- (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----------------- ....... REVIEWED BY------ ..... DATE-------- !r!�L--- ------_-_------- BUILDING PERMIT ISSUED-------------------------------------- •--- ---- ------ ---------------------------------- -DATE--------------------I--------------------- ---- ---------------------- Alterations and/or recommendations:------------------- ------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------- ---------------- --------------------------- --------------------------------------------- ---------- -------------------------------------- --------------- -------------•------------------------------------------------- --------------------------------- ---------------------------------------------------------------------------------------------------------------------------- --------------------- ...... ........ -------------- ....... ----------_A t'04 %- -., 1/ - ------------------------------------------••-- 1-------------------------------9- ----------------- ------------- -2� L FINAL INSPECTION BY:------ Date----------- ------------------------------------- .............. 9)..... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfreat 300 West Oak Street 132 Sycamore Street 914 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9 145446 ATWOCD