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a+' APPLICATION FOR SANITATION PERMIT Permit No. Duplicate)(Complete in Du li p� ) Date Issued 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 OCATION.. .;a�._d__ ___. -'P . - ---------- ------•-------• ----- - --Q a Ix�: = r�7, I ..... ---------- Phone------------------------------------ Owners Name---� Address-----`33.9_0..... 10�_'......1f _ _- _T-------------------_-- - Contractors Name----- ►_�-N..-...... ---------------•--•---------------•--•----- -----•--- Phone,/z` ..f Installation will serve: Residence t parfinen+ House ❑ Commercial E] Trailer Court [IMotel [IOther ❑ Number of living units: _f---- Number of bedrooms .--_ Number of baths --r-.- Lot size --- - ...... -_!_. G----------------------------- w Water Supply: Public system RCommunity system ❑ Private ❑ Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [4-- Hardpan ❑ Previous Application Made: Yes ❑; No E3---New Construction: Yes ❑ No [ -- TYPE OF INSTALLATION AND SPECIFICATIONS: .(No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: f Distance from nearest well-----------------Distance from foundation-_------------.--_.Material----------------------.-------------------------- ❑ L"X+S'Y1No. of compartments------------- ------------Size------------------------------..Liquid depth---------- ---- ----------Capacity----------------------- Disposal Field: Distance from nearest weEl------- ---------Distance from foundation.---_------_:::...'-Distance to nearest lot line.-__.-__.---_-_._ ❑ / rff n� Number of lines'.----------------------------------Length of each line-----------------------'------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------- -.Total length-----------------------------•.----------- " �_-�..___.Disfiance to nearest lot Seepage Pit: Distance to nearest well_.lV4A1'1=---Distance from foundation- [�� Number of pits....... -------:---Lining material:-f._C.- -:Size: Diameter-_- ' --..---.Depth------ -__---------------- Cesspool: Distance from nearest well---------- ------Distance from foundation---� ------.Lining material--.--.--------.-----._-------_------_. p � -- Size: diameter = ----- ---------------De th -----------------------------------I---------- ----,'Liquid Capacity-----------.----------------gals. Privy: Distance from nearest well------.-.-.*-- - --- ;nearestbuilding----------_-_--____-_....._---.----.-.-- ❑ Distance to'nearest lot line------- ----_. --'' � t ' -Yd ---------------_............------------------------------ Remodeling and/or repairing (describe)------------------- ----__--`-_' ----------------------------------------- ------•----------------------------------------•----------•------------------•-------------------------- -------- I ,. I hereby certify fhat I have prepared this application and-that the work will be-done in accordance with San Joaquin County ordinances, Sta ews, and rules and regulations of the San Joaquin Local Health District. (Signed)---- r--------------------------------------------------------•----------- --jOwner and/or'Contractor) BY= --- ------- {Title) ` (Plot plan, showing six�t, location of system in relation to wells, buildings, etc., can be placed on reverse side). s , FOR DEPARTMENT USE ONLY . APPLICATIONACCEPTED BY------------ -------- -------------------------------------------r--------- DATE------>----------------------------------------------- REVIEWED BY --------------------------------------------------- DATE------ -- --------------•--------------------- 1- --------------------% BUILDING PERMIT ISSUED---------------------------------' DATE-------_--- _. -- . Alterations and/or recommendations------------------ ------------. ------ --------------------- ----------------- ----------------------------------------•-•- ---------- --------•----- '' ��` r � 1_10– - -_ - ---------------.- --------------... --------------------- --------------- __-----------'-------•---•------------------- -------------- ------------------- ., ,. ----------------------------- --------r--------------- ----------------------..-.------------- FINAL INSPECTION BY---------- --- --- -------- --------------------• Date....... ----- ---- _�3-----7�_t--------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street X132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California CS__9-2M 145446 ATWOOO 12-54