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cc APPLICATION FOR SANITATION PERMIT Permi JNo. . -__1 ... � L� (Complete in Duplicate) Date Issued Applica+ion is hereby made to the Sari 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 O AT _ _ _ {/ //�'� y/�/} --- - ----------------------------------------------------•-------------- - Owner's Name----- -- - -•--------------------••------------- ------- ----------------- -------- ----- - Phone------------- ----------- •-------- c Address-•.--•------_- - - - -------------------- Contractor's Nama_ ---------------- ----- Phone---------- -------------------- Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _I---- Number of bedrooms __`-- Number of baths ---/. Lot size -------a1 ---X_te_0-------------------- It.Water Supply: Public system &?--Community system [I Private ❑ Depth to Water Table f:s- ft. Character of soil to a depth of 3 fee;. Sand ❑ Gravel ❑ Sandy Loam ❑ Clay,Loam ❑ Clay ❑ Adobe &ardpan ❑ Previous Application Made: Yes ❑ No FT� New Construction: Yes ❑ No R�-- TYPE,OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) fAt Septic Tank: Distance from nearest ' well__ Distanfrom foundation-----/V--------Mate`._ ' ------- � No. of compartments.._... ------Size.-� Liquid depth----- Capacity---y s Disposal Field: Distance from nearest well_ %•Distance from foundation----��_._---_.Distance to nearest lot line-T-of..-_____- Number of lines--:--__-----------------=------- Length of each line------- -----�f_._.W'sdth of trench----_- Type of filter materia!___._ Depth of filter material----...� ..� -_-Total length__._.... _---------------..__-_ Seepage Pit: Distance to nearest well_,'" Distance from fou ation_-_J�.-------Distance to nearest lot line-.-- ?U V` [jam" Number of pits------/------------Lining maternal_ '. "--_.Size: Diameter-- ------- - --Depth Distance from nearest well-----------------Distance from foundation-----.--------------Lining material-_._-__-_._--_.-____._.---------.__.- 4 ❑ Size: Diameter--------------=----------------------Depth----------:-------------------------- --------------Liquid Capacity------------------ ------gals. { Privy: Distance from nearest welL.....................s__.___-------------------Distance from nearest building-.--_---__-._._------------__-_--_____._. \ Distancefo nearest lot line------------=------ - -- --- ------------- ---------•--------- •-------------------------------------------------•------- Remodeling and/or repairing (describe):------- - - -------- ---- -- lo _-_--_•----------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------- ---- ----------- •._'_--._-_ -------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and,+hat 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. (Signed)----------------- � �'� G -vC"C � �-------- (Owner and/or Contractor) By:----------------------------------- ------ 1 �'"`------ A (Ti+lel _' ------ - - Plot lan. showing size of lot, to ion of systemfion to wells, buildings, etc., can be plated on revers side). ( p FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY t - ------------------------------------ DATE----------5 --------------------------------------- 1 REVIEWEDBY-------------------------- ` --------------------- DATE._ ---- ------ 1 BUILDING PERMIT ISSUED --------------------------- DATE----------------- ---- Alterations and/or recommendations------------------------ --- / _ w -------- ----- �----------- I �---�'�'----------------'---- ----.' --------------------- - -- ----- - -- `-------- ------------- -------------- --------- --------- ------------- ------ - - FINAL INSPECTION BY:---------------------------- ------------- Date_ ""------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT T ° 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Es-'3-2M 145446 ATWODD 12-54