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�\ APPLICATION FOR SANITATION PERMIT Permit No. ..4P_ Qa.... (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 Or ' ante No. 549. JOB ADDRESS P lD ATI ....Z--O---Z. ` _ ---------------------------------------------------------------------•-- Owner's Name----t t '.. !- ------- ----- ------ -- ----- -- Phone.................................... Address....----�-�� 3... Contractor's Name---- ------ ................... . . ------.......------------------------------------------......-------•-------_.. Phone--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: J..... umber of bedrooms -------- Number of baths ........ Lot size ------------------------------------------------------------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: S dZ Gravel E] Sandy Loam E] Clay Loam E] Clay C] Adobe 001kardpan ❑ Previous Application Made: Yes E] No New Construction: Yes ❑ N ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is av ' I �t in 200 feet.) Septic Tank: Distance from nearest well_-,______________Distance m f undation.....__...._._..._..Material-----_-_--__-___-_-___-._---•----_-_.-_._____.__. ❑ No. of compartments--------------------- S -- ---------------------------Liquid depth_.------------------------Capacity---------- ------ Disposal Field: Distance from nearest well.---------------- . tante from foundation--------------------Distance to nearest lot line................. ❑ Number of lines_________________________________ ength of each line-_-_--_--..______--_--........Width of trench_______-_.--------__--.____-__----• Type of filter material-------------------------Depth of filter material-----------------------Total length........................................._ Seepage Pit: Distance to nearest w Distance from foundation....................Distance to nearest lot line................. ❑ Number of its_________ ___________Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance fro ne st well_________________Distance from foundation--------------------Lining material--.------..-__._-____-_--______•___•-. ❑ Size: Diame e -----11----------------- -----------Depth-------------------------------------------------- Liquid Capacity---------------------------gals. 0 Privy- 0,/ Distance fr nea st well------------------------------------------------- from nearest building-__-------------------------------------- Distancet nearest lot line----------------------------•--------------- ......................... ...........................................................----------- Remodelin and/or repairing (des ribe) -------------------------- --- ---------•----•-----------------------•--------- ---------•-----•-------� --- -- --- ------------ - ----- -- . ------- ry ---------- . ---- --------- ---- -' ----------------------------------------------------------------------------------------------------------------- I hereby certify that I ha a prtared this a plication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rues and regulations of the San Joaquin Local Health District. (Signed).... ------------------------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)--------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings;etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY . APPLICATION ACCEPTED BY --------- --- DATE.�'=".---------•--..................................... REVIEWEDBY---------_------------- -------------------------------------------------------- DATE--- ... BUILDINGPERMIT ISSUED -----------------------------------------------............................................... DATE-------Qt'- -- Alterations and/or recommendations------------------ ---------------------------------------------------------------------------------------S- \..---••------------------------------------ ----------•-----•--...-•-----•----•------------------------------------------------------------------- --------------•---------------------- ------....-•--------...------------•-------••---•--------------...--------- ---------------------------------------------------------•------------------------- ------------------ ................................------------•-----------•-------•--------•--------------------------------------- --------------------------------------------------------------------------------------------------------------- ------------------------------ .................... ----•------------•-----•----•---•------------------- -----------------------------------------------------------------------------------------------------------------•----------------------------------------------------------.....---•-----------............................ FINAL INSPECTION BY----------- ---NX , l 7— 11 - 31 ------------------------- 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 ES-9-2M 145446 ATW000 12-54