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APPLICATION FOR SANITATION PERMIT Permit No. -' - '-.•.••-- CtiD (Complete n upliicate y ) Date issued ___��?-.-_��--5_ Applica�ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This ap�p+licatio is made`in complia ce wi# ounty Ordinance No. 549, JOB ADDRES AND LOCAT = , � 'Q _!�_ { ------ Owner's ---Owner's Name--- / .. -_-------•------------- ---------- ------------------------------------------- Phone . Address---------------------------------- v-- ---- -----..._ ----•------------•-�-----------------------------•- ----- ._--------------------------------- . ? _ 10 r?,tee crx-�e- Z •-------------------- Phone----------------------------------- Contractor's Name------------- Installation will serve: Residence Pa Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [] Other ❑ Number of living units: Number of bedrooms J__ Number of baths .4--- Lot size -----------------__----------- Water -----=---------•--•---------•- Water Supply: Public system ❑ Community system ❑ Private W]`Depth to Water Table _f ft. Character of soil to a depth of 3 feet: SandGravel ❑ Sandy Loam 8000ay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No 1�— New Construction: Yes n—no ❑ - TYPE~OFlNSTALLATlON AND SPECIFIC 10 r ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) s ,e � ---------.Material---li --_ Septic Tank: Distance from nearest well--0.-P___-_Distance f�'Qm foundation__._-� � f -- -- ----��-------- No. of compartments.....{(-----------------Size--- IP_ --_ -�--Liquid depth---- -�.------.--.--Capacity---- �. --------- r f f Disposal Field: Distance from nearest well_��.-__----Distance from foundation-----,CG9- ___.._Distance to nearest lot line-_�----_----- Number of lines-------- ------------------- Length of each line-----r�e_f�..._--.-.Width of french._-__ ei -- ----------------------- Type os filter material-_.., ---.-Depth of filter material.._., -_------_-.Total length-_--_1_ -_-.-_--_____---_-__-- k.. , Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line.--------__----.-- ❑ Number of pits----------------------Lining material----------.------------Size: Diameter--------------.........Depth-----------------------------.--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------.---.-__--_--. ❑ Size: Diameter-------------------------- ----------Depth----------------------------..............----------Liquid Capacity-.--------------------------gal . Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------------.-----.-----_-__-.---_-----. ❑ Distance to nearest lot line--- -------------------- ---•------------------------- ------------------------ ------------------------------ ------------------------------ Remodelingand/or repairing (describe)---- --------------------- ------------ --------------• -----------------------••-•-•-------------------------------•---------•---------------------- ---------••------------•------------------------------------------------------------- ------------------------------------ ------------------------•------------------------------------------------------- ---------- ----------------------------------------------------------------------------------------------------------------•-------------------------------------------•-- ---------------•-----------•---------------- ---- -- \ --------------------------------------------------------------- ------- ------------------------•----------•-•----------------•------------•-----------------------------•-----------•-•------------- - I hereby certify Pall have prepar this application and that the work will be done in accordance with San Joaquin County ordinances, State l s nd rules and ulations of the San Joaquin Local Health District. ..--- •;-�(Signed�=----`•-"=------- - --•-- ---------•-�--- -� ---=---------=----==--�r-:...-----=-----------•-=--=-----------•---•---•• ------(Owner and/.or_ Contractor)�....� IBy:---------- ----- - -- - --------- '�'--- - ----(Ti#!e� ------ --------- ------ ---------------------- (Plot plan, showing size of lot, location of syste n relation #o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY. ?_ DATER__ ---------------- ---------- ------------------------------------------------------------------------------- REVIEREVIEWED BY-------------------------------T�--- ------------------------------ --------------------------------------- Z-1 WED --------------•----•-------•-•------------ SUlLQING PERMIT ISSUED -- DATE----- �--------------------- -------------- -- Alterations and/or recommendations----------- --------------- 1.........................----------------------------•-•--------------------------------------------------.------------••---------- ---------------------------------------------------------------- ---------- ------ ----------------- --------------------•------- ----------------- -------------- ------------ --•----------------------- ------------- ----------- ---------------------------------------- FINALINSPECTION BY:-...--- ----------- -•-------------------------- Date.....VIe_ -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California -2M 145496 ATWOOO 12.54 F