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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �.J Date Issued ----1171 / 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. Q3� (, ` ------------- - --------------------------------------------------- -------------- JOB ADDRESS AND LOCATION----------_�Owner's Name. 1 t 1 [ Y'( ---------- Y £��f-- ----- " ` '�'�'� Phone ---------- Address----------------------------------------------------- ! -- l = Contractor's Name-------------••---------- 1•: Phone 4 ---------------------- Installation ____________________ Installation will serve: Residence ❑ Apartment House ❑ Commercial Z Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ___' Number of baths----- Lot size --------- _-__, �-?�_- __________________-- Water Supply: , Public system ❑ Community system Private ❑. Depth to Water Table -------- f+. Character of soil to a depth of 3 feet: Sand ❑ 'Gravel ❑ Sandy Loam-[] Clay Loam [] Clay ❑ Aclobek Hardpan ❑ Previous Application Made: Yes ❑ Nog New Construction: Yes® No ❑ F TYPE OF INSTALLATION AND SPECIFICATIONS: ✓; in 200 feet.} (No septic tank or cesspool permitted if public sewer is available with ...... ... + 4 Septic Tank: Distance from nearest well......(?_-----Distance from foundation------it)-----------Material____________ No. of compartments----------- -----------Size----- '-- --�'- ---Liquid depjh---------- -------.Capacity------ -__---- Disposal Field: Distance from nearest well.....50' .._..Distance from foundation-_----�cz_ ----Distance to nearest lot line-----S______._. w Number of lines------t--------�____ Length of each line-__-____/l?Q_/00--.0 of trench.--------- _`--- --_ ___ ' l 131 Type of filter material_______�.lj,._________-Depth of filter material___--1--y-_____.--_-Total length______________�aL?________._________- LN Seepage Pit: Distance fo nearest well------------_-_---_Distance from foundation___________________Distance to nearest lot line----------------- Number _-___ --__--_-- Number of pits---------- -----------Lining material-----------------------Size: Diameter------------------------Dept h---------------------------------. Cesspool: Distance from nearest well-------------- Distance from foundation__.----------_--_-_.Lining material----------------------------_________ Size: Diameter------ _{Depth -----------------------------t n=Liquid CaP' tl! _- gals. - . r Privy-.' Distance,from nearest well--------------------------------------------------Distance from nearest building------------------- ------------------------ Distance _---_-.___---__-_________ _ -_- -------- Distance to nearest-lot line__----------- -- --•---`------- ---------------------------------------- w Re modelin or epain tribe]__ ___________________________ __ i 1. - -. _ a& --------�c ----------- �'1.. �'_ _v�_-...�_ ------------------------ ---------- -------------------------------------- --------- ----------------------------------------- ----------------------_--------------------------------------__________________________________________________________________________________________________________________________________________________________________ I hereby certify that I have.pirepared this application and that the work will-be done in accordance with San Joaquin County ordinances, St a laws, and rules and regul tions of the San Joaquin Local Health District. ------. (Signed} ' !/ r - -- - ---------- -------- ------------------------- ---------------- ------------- -------------------------(Owner and/or Contractor} Plot Ian, showing size of lot, location of system in relat Title r •-----------------------------------------( � )-------------------------------------- ------------------------- { P 9 y ion to wells, buildings, etc., can be placed on reverse side}. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- ---------------- _ DATE-----------•- REVIEWED BY--------------- • -- f . --- DATE ----- -----------------•--------------- BUILDING PERMIT ISSUED----'---------•----------------------------------------------------------------------------------------- DATE. Alterations and/or recommendations:._______- _ - .---- ' '------------- _ ^1 e-11 I rr- �'4---:_... ... ----•--- - -------- --- -- ------ --- -- -- -- --- ----- ----- - - -- - - ... __ _. [ ...f .-.______.__ . � -• ----------------------- --------------------- FINAL• INSPECTION BY------------ -------�---------------- -•--- =------ Date------------ e-- - -- ----------------•------- SANuJOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfrset 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised VNo_