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+ � APPLICATION FOR SANITATION PERMIT Permit No. ----- _ a (Complete in Duplicate) { / Dk-�LoA*wA- L-�' Date Issued --- Application 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 w• ounty Ordinance No, 549. JOB ADDRESS ANDLOCATI ____ __ __��_�r�____ -------------- - `--- - Owner's Name.------. [°� �'�'� ------ ------ - ---- --------------------------------------- Phone------------------------------------ Address-------------_-----------------_ Contractor's Name--- ------ ---------- -------------------------------------------- Phone----••--••------------------------- Installation will serve: Residence UP--Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms -.3-- Number of baths __Z__ Lot size -----_______________________ Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeColHardpan Previous Application Made: Yes ❑ No � 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: Distance from nearest w _ I__N Distance/f�om foundation Material____.. __ _ No. of com artments..... ..... ... r p -,-�------Size 1�---X-11-----Liquid depth------- � Capacity----- ..... Disposal Field:Field: Distance from nearest well...!lil471. Distance from foundatiof�___ f�.._____.__Distance to nearest lot line-__ ___ Number of lines-----------�.__.�_-__...--- Length of each line______7rr-_____`--__.._.width of french.___�°�_. ...... Type or filter material______] epth of filter material __.._4f----------Total length------«_ ______-_ s � Seepage Pit: Distance to nearest well "1 ___Distance from founc tion___ D_____-__.D•stance to nearest lot lineJ_�__-__--. ArNumber of pits__.___,?-----------Lining material__L�_±�_ Size: Diameter__-- ------ ___.Depth...... Cesspool: Distance from nearest well------------_____Distance from foundation------.-------------Lining material-------------------------.__________Ej . Size: Diameter------------------------------- _----Depth----------------------------------------------------Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------.-----------Distance from nearest building----------------------..______.__._____._ ❑ Distance to nearest lot line--------- -------------------•--- -- ------- - ---------•---------------•-•----------------------------------------------•------------------- Remodeling and/or repairing (describe):--------- '``' ---- l - ��'�__ -----------•-------------------------------------•--•t .-- ----•----------------••---------------------------- ------------------------- ----- ---•------------- ---------------------------•---•----------------•- ------•------------------------------------- •-----------------------------•---•-----------------------•------------------------ --------------••-----------------------------------------------._.-•----------------------- 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 r es and regulations of the San Joaquin Local Health District. I (Signed) �4i t� � ._ _��' -----•--- [ i�"Sr Contractor BY:----•---------------- -------- -- [Title)-------- ---------------------- (Plot =------- --- � ---------------------------------------- �� [Plot plan, showing size of to , cation of system in relation to wells, buildings, etc., can be placed ffn reverse said ). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------- --- -- -- - - - -- ---- -- -- ---------------------------------------- DATE---- - -- ----•--------------------- REVIEWEDBY------ --------------------------- - - - - - - --- - ------------ ------------------------------------------------ DATE------ --- BUILDING PERMIT ISSUED-------------------------------- - ------ --------------------------------------------------- DATE--------- Alterations and/or recommendations-------- ------ --- ------I-------------------------------------------•----------------------- Z`--------- -------r --------- --- - - ------ -- - -------------------------- �- - --- --------------------------------------- = -•---- ------------------------------------------------------- ---------------------------------- ------ -------- .--------- - -- FINAL INSPECTION -----•--------------------------------- Date..--- -----f-7`----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California a E5�3-2M � 145446 ATW09O 12-Sa. r � -