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APPLICATION FOR SANITATION PERMIT Permit No. __-l•L_��- - 1 in Duplicate)(Complete P ) Date Issued __Y�s'�/-?--� Application is hereby made to the San Joaquin. Local Health District for a per hit to constru 11 'and install the work herein described. This application is made in compliance with County Ordinance No. 549. r JOB ADDRESS ANDILOCATION__{ � --- Phone----- i' 7fJ e ^° ',1C�G - } Owner's Name ---------------------- ------- --- a__ - - - : ------ Address----------------••- ----- � ---- ---cs.�:_,�rn-�� ---=-�---- ----- ---- - Phone_ Contractor's Name------------------ `►T------- i Installation will serve: Residence ❑ Apartment House E.3Commercial Trailer Court El Motel E] Other El `J Number of living units- _-------.Number of bedrooms -------- Number of baths _-'Z_ Lot size ---e�,(C----- '__ - -••------•--------------- Water Supply: Public[system Community- system ❑ Private ❑ Depth to Water Table 4fOft- I Character of sol! to a`depth of 3 feet: Sand E] Gravel El Sandy Loam El Clay Loam El Clay ❑ Adobe Hardpan C1 Previous Application Made: Yes ❑ No I New Construction: Yes ❑ No PHA/VA: Yes ❑ NoA TYPE OF INSTALLATION AND SPECIFICATIONS:.1, " (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sepfic�ank" Distance from nearest well-----------------Distance from foundation-------------------Material----_-.:----.---_-_-_.----_---_-----.__-.___-. No. of compartments----- ----Size---------------•----------------Liquid depth--------------------------Capacity-------------- - - --------------- ispo i Id Distance from nearest eN--AJ-14 Distance from foundation---/Q_`------Distance to nearest lot lin��-. _ �- Len th of each line-_---- --v----_---.Width oftrench------�-�-------------------- i �- Number of lines----------- -----''��""- ---------- 9 Type of filter material----:-;P4_C„f ---Depth of filter material_---- �:.___------Total length_------_/------------------- Seepa a Pit: Distance to nearest well-_--/cf0A/4__Distance from foundation---. _ ___.Dista��e to nearest lot line f-7-------- 3_11 O Linin material------ __Size: Diameter_,3 ----_------Depth--- --------•-------- Number of pits---- -------- Lining Cesspool: Distance from'nearest well-----------------Distance from foundation--- _--_ Lining material -_.------_.---- als. �4 ❑ - -Liquid Capacity--------------------------- iSize: Qiameter---------------------------------------Depth- ----------------------------------- ------- g Distance from nearest building----------------------------------------- \` ' Priv Distance frominearest well------------------------------------- �1 Y=. ❑ Distance to nearest lot line------- ---------- -------- -------- -•-------------------- �--------- Remodeling and/or repairing Idescribe):__-__ - _ ----------- _______ ______•---_ -_------ -- (p - -�:____-- _-_-_ _- �14_!- r�- -__ - -'-------------'----- I here-- ---------- ------ ------- -------- ----- ------ - --- ---- - by certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,' Sta#e laws, an rules and regula ' n of the San Joaquin Local Health District~ ' ti '---------------------(Owner and/or Contractor) (Signed)----------------- =--� %-ti ---=------ By:-----------------------:----------------------------------- � -- - --- - ------[Title)----- ---�----�---'-`�``--- . (Plot plan, showing size of lot; location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- - ____--_ - DATE------- 1----------------------------- REVIEWED BY--------------------------------------------------- ---------- ---------- -----------------------• ------------ -- ------ DATE---------------------------------------------------------- --------------------------------------------- DATE-------------------------------- Alterations PERMIT 1S5UED---------------------------- - Alterations and/or recommendations--------------------------- --------------------------------------------------------- -- - ---- ----- ---- ------ - {- •--- � s7 - - ------ ------ -------------------- --------------------------- Date-------°� ' -_ --------------- --------------------------------- FINAL INSPECTION-BY::-�__--._. -- _ - - •` - -- SAN JOAQUIN LOCAL HEALTH DISTRICT 13o 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 Revised 1.57 FY,COI