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f' APPLICATION FOR SANITATION PERMIT Permit No. A-9.7-3------ (Complete in Duplicate) 1 r S 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 A OCATION -�`"- `---.---� - ___ -__-_ _ _. :--- --------- --- Owner's Name--- -- --- --•------ ----• --------- ------- -- ---- --- ----•--- {�� ` - �- --- -- Phone------ Address------ ._r ......... --• -- -------- ------------------------------------------------------•-- ------•-•-•-•--•--------------•-----------------�--------- Contractor's Name--------------- --- �"-------•--•-------------•---------------------------------------------------------------------- Phone... ,✓'`. f.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms .2_. Number of baths I___ Lot size ._„ dX_1_„----------------_----._---- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Ta6le,4�Qft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes F] No f� New Construction: Yes1w No E] // A� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weft________________Distance from foundation_-_--.--.-_--_-_--Material--.-----..----__._.__-..-_--_-----..-__..._-..._. No. of compartments--------------------------Size-------------------------------Liquid depth-------------------------Capacity-------------- ---- - Dispos I ield: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line-------_._--_---- Number of lines-----------------------------------Length of each line------------------------------Width of trench-----------_--_..___._-------__-- Type of filter material......................._Depth of filter material___..__.._..._._____.Total length---------------.------.,-________________. 0) Seepage Pit: Distance to nearest well......_-Distance f om fo ndation_- _�...___....Distance to nearest lot line--S0_____ N Number of pits------/""------------Lining material Size: iameter--�/ ....Depth.�t� + ------- _r Cesspool: Distance from nearest well-----------------Distance from foundation _Lining material-____.__-----------.---------.------. ❑ Size: Diameter---------------- Depth------------------------------ ---------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------__--------Distance from nearest building.__--.-_-___.______-_---__---.--------. ❑ Distance to nearest lot 5re----------------------------- ------------------------- --------------•--------------------------------------------------------------------- Remo ell and/or r i e G"_.-y- - -------- � �•- i¢r� ----------•-•-----------------------•--------------•--- ...... ------------ --------------------------------------------------------------- ------- ---------- ---- ---•------------•-••--------------•--------------_.---------------------------------------------------------------------------------------------------------------------------------- ----- -- - - - ----- --- ------------------•-------------------- ---•---••---•-----------------------------------------------------------------------------•----------------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat s, a Oes and regulations of the San Joaquin Local Health District. (Signed)...---------..... . ......' __ _ (Owner and/or Contractor) By:........................... .. _L!.. .. Y ----- ------------ ---------- -------------------------------------------- Title -�------------------- - ------ --------- (Piot plan, showing size o lot, location of system in relation to wells, buildings, etc., can be p cad reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_.......... --------- --- ------------------------------------------------------ -- DATE----::7:2------------------------------------------ REVIEWED BY------------------------- ------ DATE------ --------<r�<�--------------------------------- BUILDING PERMIT ISSUED------------------------ ---------------------------------------------------- DATE------ -- ------ -----------------•----- --- ------------ Alterations and/or recommendations:--------- ------------- --------------------------------------------- •------....------ -•------------------------•----------------- ---•----------------------------------------------------- ------------------------------------ --------------------------------------•-- ------------------------------ ::---------- -- -- ::�:: -:-:---- ----:::::_:_::::::-- --:--::::------::------:---------:--:-:---------:------------------------------:_----------------:---:---------- ---------------- ------------------------------------------------- ------- ----------------------.------------------------------------------------------------------------------------------------------------- FINAL ----------------------------- J FINAL INSPECTION �C---------------------------- Date_.... ------------------------------------------------------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT ti 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California -2M 145446 AT WO�� 12-5q