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APPLICATION FOR SANITATION PERMIT Permit No. -__2.2__-�_L_ (Complete in Duplicate) Date Issued ___3 ) F 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. 544. JOB ADDRESS AND OCATION----/Le ° ------------ --- •--------- Phone------ ------- Phone-----• ----•------------- Owner's Name--------- =-- O - ----------•-----..__.. - ------ ---------------------------------- ----•-•---- ----.--.-.--------••--- ---------.. --------------- Address-----•---._ 1 -- ---- Phone. ....__... - - --------. Contractor's Nam � L Installation will serve: Residence Apartment House [I Commercial ❑ Trailer Court ❑ Motel ❑ Other El Number of living units: _---- Number of bedrooms __-•�_Number of baths -_1---- Lot size ------- � - ------------------------- - Water Supply: Public system [� Community system F-1Privateto Water Table ft..Private ❑ p Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe RL Hardpan ❑ Previous Application Made: Yes ❑f No 54- New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.} 01 Septic Tank: Distance from nearest well-.-_________.__Distance from foundation_______________ Material-___-__-____-____-__-.-------------------------- ❑ of compartments----- --------------- --Size-------------------------------•Liquid depth ----------•--- ---------Capacity-------------------j Disposal Field: istance from nearest well-.-.e Q istance from foundation____ZQ---- _.Distance to nearest lot line__.___. Number of lines_______________� Length of each line_-_____'?e _ - .__.Width of trench-_.__ - ------------------ 7 »�----- Type of filter material--- filter material_._.__-l ---------Total length-______ - ----•--------- P Seepage Pit: � Distance to nearest welL___��-Distance from foundation-----��._______.Distance to nearest lot line----- Number of pits-------/------------Lining mater -C,/�.&C Diameter---.-�?-, - -----Depth------ --------- -- 54- p ;nearest well__-----_-___--_-Distance from foundation-_----_-_._____--..Lining material__'-- ------------ ---- Cess ---- Cesspool: Size: I3iame#er'' ------ --------De�nth------------------------------ ---------------------Liquid Capacity----------------------------9 Q Distance from Privy: Distance from nearest well-------------------------------------- Distance from nearest building------------------------------------------ \� ❑ Distance to nearest lot line------ -----------------------------------------------------••-----•--------•---------...------ - --------------- --------- ? Remodeling and/or repairing (describe):------------ ------------- ------------------------------------ --••---------••---- ------•----•-•---------------------•-------•------------ ---- ------------------------------ ----- ------ -- --•---- -•-------------•---------------------------------------------•. - - - Coun application and that the work will be done in accordance with San Joaquin +Y ! hereby�certif that I have prepared this appl � ordinances, St a s, and rules and regulations of the San Joaquin Local Health District. (Signed) ------ -------------------------------------------------- ------(Owner and/or Contract ---------------------------------(Title)----- ------------------------------------------ f (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 BUILDING PERMIT ISSUED----- •---------- ----�\ �y -------------------------- DATE ------- Alterations and/or recommendations: - ------------ -----------------------------------------------•------- - -------------- --------------•--------------------------• --••----------------•--------------- f , � ----------- -- -- ,v --- -- -------- ---------'------- __- - ---------.----'--------------------- ----- ----------------- ---- ------- --------------------------- FINAL INSPECTION BY:---- ---'�------ --------- -- --------------------- Date---------- -----•----- -------------------------- - SAN JOAQUIN LOCAL HEALTH DISTRICT 300 Weal Oak Street 132 Sycamore Street $14 North "C' Street , 130 South American Streit Trac California Stockton, California Lodi, California Manteca, California y� E5-4-2M 145446 A7W Ot10 12-54