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N � s� APPLICATION FOR SANITATION PERMIT Permit No. .............:...... -. (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 LOCATION_________________________ ___.__ _ __ I %� 11' f �l� .. Phone Owner's Name---------------------- ° f "----•-- ------- -----_--- ------- -------- Address------------------- ° LTJX_5;!,n----- -- ------------------------ Phone_A® Contractor's Name------------------ - -••- -----��-��'-#�-�-�a-`--------- ---------------- Installation will serve: Residence Apartment Douse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ~�---�-�-'-'.�---------------------- Number of living units: ----1_ Number of bedrooms ---/.- Number of baths _ ----- Lot $ize ---�.� � Water Supply: Public system �ommunity system ❑ Private ❑ Depth to Water Table Character of sail to a depth of 3 feet: Sand Gravel 1-1 Sandy Loam Clay Loam ❑ Clay ❑ Adobe ardpan Ll Previous Application Made: Yes El NFO ew Construction: Yes R';No ❑ v� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public s wer is available within 200 feet.) - ___.Material_____ _ Septic Tank: Distance from iearest well---____-,f_____Distance�from f u ndation___� '41 10 No. of compartments_- --- _ i'-.--Size --:A_U!_XLiquid depth__df^ ____.-------iCapacity�Q-Q_------- `------- Disposal Field: Distance from near st wellt4"4J-.Dis4 from foundation__I-E3__-------Distance to nearest.lot line._ ` Length of each --------------Width of trench_.�--`/-..-`--.----............ ' Number of lines---- --- - --f�- g `i 1 Type of filter material__�_f1c. -_--- ---- Depth of filter material-----fS----------Total length--_ '`J----------• Seepage Pit: Distance to neares weiL� Nlk w___' Distanc fr f undation__ -�-_______.Dis nce to nearest lot Ime___ ____________ Linin material_ Size:'Diameter---s _ .... .---.Depth__,1__c7----________________ Number of pits:___.___.___.--_ g Cesspool: Distance from nearest well-----------------Distance from foundation------------_-------Lining ` material_ ---------------------- --Liquid ____.-- Li uid Capacity " . _----gals. Depth - ❑ Size: Diameter----------- ------------ ---- Privy: Distance from nearest well ___._'-----------------------------------------Distance from nearest building------------------------------------------ -------------------------------------- ❑ ------- ----------------- ----------------------------------I to nearest lot line__________--------------------------_. - Remodeling and/or repairing (describe:--------._-------------------------------------•-------•--------- ---------------------------------•-----•-------------------------------•------------ --------------------- ----------I-------•------•-----•------------------------ --•---•--- --------------------------------------------------------•----------------------•--- -•-- 'kOa�pl.iica�, __1-------------------------------------------------------------------------------------------------------------------------- -------------------------- ..» I herebyTlaws, at I have prepn and that the work will be done in accordance with San Joaquin oun y ordinances,.Sand�rule anal n Joaquin Local Health District. ----- r Contractor) Si ned ---- ------- -- - -- ------------ I Tale - �`� t'---------------------- BY:---------------•----------------------- -----( � ) (Plot plan, showing size of lot, location of system in rel n to wells, buildings, e.;can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ ------ ----------------- -----•----------------- - DATE __. REVIEWEDBY------------------------------- ----- ------------------------------------------- -------------------------------------- DATE S BUILDING PERMIT ISSUED------------------------------------------------------------------------------• DATE.--------vS ; Alterations and/or recommendations:----------------- --------------- --------------------------------------------------------- ecommen ations:_.___-____________________________________..-- ---------------------------------•---------- ------------------------•------------•----- .. FINAL INSPECTION BY:.........' _---- --- Date -----� -----f------------ I SAN JOAQUIN LOCAL HEALTH DISTRICT l300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street I Trac California Stockton, California X Lodi, California Manteca, California Y ES--9-2M Revised W-2100