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APPLICATION FOR SANITATION PERMIT Permit No. ..._ /_ /.. /!'.. (Complefe in Duplicate) Date issued ._7!'-_ �.-� ' plica io y�i n is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 1 Ap ! This application is made in compliance with County Ordinance No. 544. Q� ._ _ JOB ADDRESS AND LOCATION.-I-------- ,- 12--...----•-.;1 �'? -- ---------- -•--------•--- ` ---- Phone--------------------------- ------- Owner's Name....... C_. ._ ---------• [a{"�V e--•------ i Address----_------ f f--> r- '?a-'4:'t Phone----------------------------------- Contractor's Name------ --------- ------------ ---------------------•--- Installation will serve: Residence ®. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ CF. '.`�C--------.rU---------------------- Number of living units: ------- Number of bedrooms __ �- Number of baths --j--- tot size ___�__ . Wafer Supply: Public system Ell Community system ❑ Private,❑ Depth to Water Table . ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe d Hardpan ❑ Previous Application Made: Yes ❑ No j_ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION ANDS'PECIFiCATIONS: (No septic tank or cesspoolpermitted if public sewer is available within 200 feet.) Septic Tank- Distance from f nearest-well-----------------Distance from foundation-------------------Material-----------.-----__.__.------_-..-.-----.._.__._. ❑ o. of compartments Size-------------------------- Liquid del?t, - Capacity Disposal - d: Distance from nearest well_./1�1} t_n�3istance from foundation---.+�-� --.---Distance to nearest lot line__��_ . Number of lines---------- ----i_-.-+-T---------Length of each line----------- _-�- ---Width of trench----- -a .� ----------------- Type of filter material-_/ ---_.�,RQepth of filter material------ -- --------rota! length------' _ -;-------------------•---- '' Seepage Pit: istance to+nearest well;:r__.._. �---Distance from foundation-------------------Distance to nearest lot line-------._---_-___ N'umber of pits-------------- -------Lining materia4------ -Size: Diameter-----------------------Depth w ° I Cesspool: Distance from- nearest welL________________Distance from foundation material_.___________..___._____- - gals. ❑ Liquid Capacity- ------------- Privy: Diameter-=---------- ----------- ----------Depth-------------------------------------------- - -- _-------------- -----------Distance from nearest building-_-__..._____._______ - Privy: Distance from nearest well--------------- ----- ------------------- ❑ Distance to nearest lot line-f------- -------------------- ----------/-------------------° Remodeling and/or repairing (describe:__. /t 1 �' �..�7 '�4i." .� ��-1' to13 -/aJ �7 ,'a't/� 1 �'��-�-e--.---- ' � �-d_ _ =------- = -' -----=�=� =�' � t .�� - _ Y 4 f n'r.e I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f ` � h _____________-___--------------------------- -----------------------------------------(Owner and/or Contractor) (Signed)......ele.7 , ------------ ,rr -------(rifle).__.._r�'' "1. (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 APPLICATIONACCEPTED BY------------------ - ---- ------ - -- ------------------------------------ DATE------------------------------------------------------------ REVIEWED BY--------------------------------- -- DATE r I� BUILDING PERMIT ISSUED------------------------------ DATE Alterations and/or recommendations:---------------• - -- ----- ---------•----- •------•------•------•-------------"-- -------------------------------------------------- ------ --------------------•------------------------- •---------------- -------- FINAL INSPECTION BY:... .. .-�__._ - Date------. --------------- ----------------- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Tragi California �� t. Stockton, California .. Lodi, California Manteca, California Y• : ES-9 145446 ATWCUD