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I / APPLICATION FOR SANITATION PERMIT Permit No. .--5�3 ..... ! ' (Complete 1n Duplicate) �/ Date Issued ---411 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 LOCATIONI ..- - ---- _ . .- _ ', _ _ Owner's Name---------- --------r--------•-------•---------------------------------------------------------- --- -- -- Phone A- 0-2, Address-------------------'----- -• .f = Contractor's Name------------- ------------------------------------------------------- -•-- ----------- ------------•-.• ---------------- Phone II Installation will serve: Residence ®l"'A"partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -_`--�� Number of bedrooms -;2•- Number of baths ._/_- Lot size .1 I Water Supply: Public system I�Community system ❑ Private ❑ Depth to Water Table -------- ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam F] Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ 'I Previous Application Made: Yes ❑ No [!J-�New Construction: Yes ❑ No E TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool 'permitted if public sewer is available within 200 feet.) Septic Tank: Distancezkorri neat ell-----------------Distance from foundation--------------------Material_--__-----.--______------_-----_-__--.--__ --- ❑ No. of compartments------ --- ------ -------Size-----------------=------•-------Liquid depth-----------------------.-Capacity--------------------•-- Dis osal Field: Distance from nearest g rq Widfih of trench.__- -__ --- _ !_•,_ p r learest weli-./u'�._ _Distance from foundation-- --�-.-,_-t.Distance to nearest lot line----------------- Rr Number of lines_------- -- ----- -- Len th of each line----___ 6 $. �� . Type or filter material._- _.Depth of filter material----IS/----------.-Total length------��------------------------ IM Seepage Pit: Distance to nearest well_---__-----_-____-_-Distance from foundation--------------.-.-..Distance to nearest lot line..-__.---.---.-- ❑ Number of pitsl --------------------Lining material-----------------------Size: Diameter-----------------------Depth------ ------------------ --------- )A Cesspool: Distance from Dearest well-----------------Distance from foundation--------------------Lining material----------------:----,__------_- -- ❑ Size: Diameter-iM ----- -------------------------Depth---------------------------------- --------- -------Liquid Capacity. gals. Q Privy: Distance from nearest wO-.-.-______--------------------------_--------Distance from nearest building,--___--------_----------------_---_--. ❑ Distance to nea`rest lot line_---------- -------------- -+-- N , Remodeling and/or repairing (desciLe):------ � .. �:i� 4) � _ ------ ---- .- I4 -_---•-•------- 'v � ------------•------------------------------------------------- ------------ ------- -- ------ ----- -- ----------------------------------------------------•----------------------------------•------------------------------------------ ----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County `J ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ��' ff _Vi s°......_.� (Signed)....r:._ = _ E ------------------------------------------ -------------------------------------------I_ -- ----------------------(Owner and/or Contractor) By:--------------------------------------------!1_-------------------- ------------------------------------------------------•--------(Title)----------------------------------- -------------------------- } (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ------ - -^-- ---- - -------------------------------- I ( f . t1 DATE REVIEWED BY -- --------- ----------------- DATE � 'V- ------------ -- ----- ------- TT BUILDING PERMIT ISSUED ------------------ --------------------------- ------------- DATE t Alterations and/or recommendations:--.-/--------- ------------i• ---------------------- ---------------------------- _------------------------------ ---------------------•--- -------------- 1 i _.. --------------------------------------------------------------- ----------------------------------- - ----------------- - - .----------- --- -/_�' . A?/ I FINAL INSPECTION BY:. -I>-- .. Date.. ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California E5-9-2M 145446 ATWpoO 12-54 4 T {