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APPLICATION FOR SANITATION PERMIT Permit No. i.-- -- '�� �� . • (Complete in Duplicate) Date Issued --- A S.3 i Application is herebyiLmade to the SaniJoaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance Gwith County Ordinance No. 549. ------ ---- w-_-- ® ` 9 , ' i -----------------------•------ ------------ ------JOB ADDRESS AND OCA N ,96 4 "--- ----- Phone_Z __W7-------Owner's Name..---- Address-------- ame----- Address---.-___ I --- ---- 41 - Contractor's Name----- ___ Phone_-�--"� -- - -------------- ------- - - -- - Installation will serve: Residence Apartment House E] Commercial ❑ Trailer'Court ❑ Motel E] Other ❑ Number of living units: :---- Number of bedrooms .-;L--Number of baths . ___ Lot size -----DCL-_-�-3--;----0--------------------- Water Supply: Public system El Community system 11 PrivateDepth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel I] Sandy Loam ❑ Clay Loam ❑ Clay ❑ •Adobe Hardpan ❑ I Previous Application Made: Yes ❑ No Y New Construction: Yes>(. No ❑ , TYPE OF INSTALLATION AND SPECIFICATIONS: j, (No septic tank or cesspool permiffed if public sewer is available within 200 feet.) t Septic Tank: Distance from nea est well___-5-----__Distance from foundation____ S._____.Mate�ial____`''_________________,______________-- '` No. of compartments______------_�--------Size__S4-Y_ya_�s`_:_-_Liquid depth_.__7__,.il�._.____-_Capacity---- ---4--4---`-O k Disposal Field: Distance from nearest well..+0--.__._Distance from foundation____I+�_---.__.Distance to nearest lot line---- Disposal Number olines Length of each line________6_tl-�__.__...___..Width of f trench___ Type of filter material__$t__- b - ____Depth of filter material-------/� __--Total length------ -' _ ____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line______.____-_-._ ❑ Number of pits---- ----------------Lining .material-----------------------Size: Diameter---------- -- ---------Depth---- - ------------------------ cesspool: ' Distance from nearest well-________ ______Distance from foundation------------------:.Lining material---------------------------.____-___-- ❑ Size: Diameter------'--------------------------------Depth_-------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------Rs ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------- -------------- Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------ ------•-------•-------------•-•------••------•--------------... .� -------------------------------------------------- ------------------------------•----------------••-•-----•-•-------------------•--•------------•-•-----•-------------------------------------------------------------- ---------------- ---------------------------•------------------------------------•--------------------------•------------------------------- 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. t (Signed) - --------- --- _ ------( Owner and/or Contractor) -4 By:-----•=----- ---- .G `"r"` t -----------------------•--------------------------------(Title)- - - -- -- (Plot plan, showing size of lot, location of sy em in relation to wells, buildings, etc., can be placed on reverse side). I ( FOR DEPARTMENT USE ONLY R APPLICATION ACCEPTED BY-------- ----- -�-- -------- --------- DATE----- - --------------- - - REVIEWEDBY--------------------------------------------- ---------------•---------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------- ------------- ------ DATE--------------------------------------------- -------------- Alterationsand/or recommendations-------- -- -------------------- ------------------------------•------------••----------------------------------.-------------------------••------------------- ------------------------------------ ---------------------------------- ----•------- --- ---------------------------------------------------------------------------------------------------------------------------------------------•..... , -------------- ---- --• ------ - FINAL INSPECTION BY: - -------- Date - y�� fi SAN JOAQUIN LOCAL HEALTH DISTRICT r 130 South American Street 300 West Oak Street 132 Sycamore Stree# 814 North "C" Street + r[ Stockton, California Lodi, California Manteca, California Traty, California ES=9-2M ID-52 Revised W-2100 r