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APPLICATION FOR SANITATION PERMIT Permit No. -------_--------t. -_ (Complete in Duplicate) 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 L CATI N... 0 . Owner's Name---------- . .. C -- --------- ��.�� Ph e Address-------------------------- ---------- - •----...--•---• -- ----•----------- Contractor's Name----- ��N_r .� Yl_----- ._ Phon _.. / �� Installation will serve: Residence 2--'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J.. Number of bedrooms _>3_- Number of baths .Z Lot size 02�--------------- f ------------------•- Water Supply: Public system Te--c'Ommunity system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [2--fTardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is available within 200 feet.) te�r,�•/ - Septic NDistance from nearest well.N-4- ----------Distance from fo�u�nclation.�s� . -____ Mate -al------ No. of compartments----.off-----------Size_ _j��----�-Liquid dept�.v�_.. --------------Capacity------------ -� �rr d-�_ Disposal F' Id: Distance from nearest well.`.'I�')'t9�_Distance from foundation_--- __.__.Distance to nearest lot line_�Q___:___ Number of lines------ Length of each line-AO---------------------Width of trench---4`Z__4`�........----------- Type __________T e of filter material-----___..7lr_.. -Depth of filter material---------AP"---Total length______.�-4--__ --------------------- Seepag it: Distance to nearesjfwell. _- QiCI�.______Distancrom undation__ _ Distance to nearest lot line_______._______ Number of pits---- -----------------Lining material- %rL _ __ -----Size; Diameter _-_______Deptn_____ t , r Cesspool: Distance from nearest well-----------------Distance from foundation------------.------ Lining material______._.____..________.__.__.______ ❑ Size: Diameter_ ----------------------Depth------------------------------ -- --- --------------Liquid Capacity---------------------------gals, O Privy: Distance from nearest well ______---_----------------------------.---------Distance from nearest building__,_-___-----------_____________._.____._. [� Distance to nearest lot line--------- ------ ---------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):--------------------- ---------------------------------------------------------------------------------------------------------------------••-------•---- ------------------------------------------ ----------------------•------•----------.-------------------._.....-..--••--•------------------------•--------------------------------------------------------------------------- --- ----- _ - I hereby certify,that I . ave prep,red +his Capl,' ationand that the work will be done in accordance wi+h San Joaquin County ordinances, State lawar94 rules pnd regul the San Joaqui Local Health District. (Signed)------------------------ -- _ a_ _I_ '_._- -- _�-✓. ---- --- ---• Contractor) 6 ---- ------- a (Tatie) By: -------------------------------------------- -- ---------------- (Plot plan, showing size of lot, location of system in relation to well buildings, et can be placed on reverse side). , FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ----- -------- - --- - - ------------------------ ---------------------------------------- DATE------ -- -- - --•---• ---------------- REVIEWED BY ----- ................ ---- ----- - DATE BUILDINGPERMIT ISSUED-------------------- - ----------------------- ---------------------•----------------------------- DATE------0--------------------------- ---------------- Alterations and/or recommendations:------ --- --------------------------------------------------------------------•--...._._------•-•------V1 -------------------------------•-------------------•----------------- ------------- - ------- - ------- ----------------------------------------------------------------------------•---------------------------------------- --------------------------------------------------------------- --- -- - ---------------------------------------•--•------------------------------------------------- -----••--------------------------------------------- ----------------__----- --------------------------•-------------------------------------------------------------------------------------•---------- -----------------------------... -----•--•----•----•-----••----•-- ------------------------------------------- --- ----------------------------------------- ----------------------------------- --------- ------------------------------------------------------------------------ FINAL INSPECTION BY: ----------------- Date---. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California Er' 9-2M l4544G ATwoo❑ 12-5a