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i + Permit No. APPLICATION FOR FOR SANITATION PERMIT (Complete in Duplicate) Date Issued __� - -- + e to the Sa Joaquin Local Health District for a permit to construct and install the work herein described Applica . ion is hereby mad This application is made in compliance with County Ordinance No. 549. ----- �'L�.-1. -`�. --------------•------------ JOB ADDRESS AND LOCATION______ _______ - .�,. - ------------------------- .......... Phone----•---------------------•----••---- Owner's Name--------------------- --- -----.- , Address----------------•-------•-------• ---------------- Phone---_------------------------Contractor's Name------------------------------- Trailer Court ❑ Motel ❑ Other Installation will serve: ResidenceApartment House ❑ Commercial ❑ i Number of living units: 2---_ Number of bedrooms 3_-- Number of baths ___I___ Lot size -- - ----- Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table 4---- ft' Adobe Hardpan Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ ❑ ❑ Previous Application Made: Yes ❑ :No New Construction: Yeses "o ❑ A� �,. . TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer, is available within 200 feet.) Material-- Septic Tank: Distance from nearest well-/042 "stance from foundation__ ___________ __ ? Sx- ,_ _�-.---Liquid depth_. ----Capacity-- y° t . No. of compartments......... .......... r if Disposal Field: Distance from nearest well----- v� ---Distance from foundation_- -f. _-_.__.._.Distance to nearest lot 1e__..-�______...-� Number of lines---•----- -r'-----• Length of each line--.1.5----rr,,-----------Width of trench----�-tf--------------------- -Depth of filter material------J--7�------------Total length------1 �------------------------ TypeTy of filter material__.5.,- p L Seepage Pit: Distance to nearest well----------------------Distance from foundatieon------------ Number -a }�f-.-.Distance to nearest lot line_--------------- L _- -----__ ' Number of pits----- ------Lining material------ ------------ C ❑ ___.Linin material Cesspool: Dista rice from nearest well_______________pistance from foundation __ __ g - gal5- [__1 . Size: Diameter'--------------- -------- --------Depth----------------------------- ------ --------------Liquid Capaci#y--------------------------- ❑ Distance from nearest building------------------------------------------ Privy: Distance from nearest Well------------------------------------ - ------------ :T ---- ---------------------- ❑ Distance to nearest lot ine________________________ - _ .t u eling and/or repairing ( escii e :_- -- ------------------ Remod ------------------------------- ----------------------------------------------------------- ---------------- -------•-- •------- -- -------- 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. 4- ----------_ _(owner and/or Contractor) L-. -- (Title) . ey- - -- - --- ------- -- --- -- - ------ - - e) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side]. ' R DEWTME USE Of LY f ` . ------. ......... -•----- DATE----- APPLICATION ACCEPTED BY. DATE-------------------•-------------------•------------------- REVIEWEDBY-------------------------------------------------------------- ----- DATE.----------------------------------------------------•------ F BUILDING PERMIT ISSUED----------------------------------- -------------- i Alterations and/or recommendations:------- ------ ........... . ------ -- -------- ------- ---------------------------------------------------- :. ---•- -- ---- --•- --------------------- ------ --------- - ----------------------------------------------- -------- ---------------.--- ----- ----------------- -------- x ------ i FINAL INSPECTION BY---- ------- -- ---- ---------- ----- ----�-------- --- Date----- �L- SAN JOAQUIN LOCAL HEALTH DISTRICT j 132 Sycamore Street 814 North "C" Street t.«.. 13o South American Street 300 West Oak Street Trac California Stockton, California Lodi, California Manteca, California Y� f E."-.-9-2M 595x46 ATWODO 12-54 � �� W