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AAII b� APPLICATION FOR SANITATION PERMIT, Permit No. ...LI.�.G.3..._-. (Complete in Duplicate) Date Issued --- Applica,'ion is hereby made to the Sen Joaquin Local Health District for a permit to construct �ntall�thg work herein described. This application is made in compliance with County Ordinance No. 549. 15 -I'' •v�r�+ f JOB ADDRESS AND LOCATION....-- - .......... Phone Phone... Owner's Name...............:. .............. .......... .... ..... Address--------- ---- ... on . -- _.. Ph e. --- -ter--- Contractor's Name__...- .._ .. ------... ...... .......... ...•_-• ---•- � ----•• Installation will serve: Residence Q�_ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms .-. ..- Number of baths ,. Lot size ... Water Supply: Public system ❑ Community system ❑ Private ❑ Depth-to Water Table '40t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes M_No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ( p p p f public sewer is available within 200 feet.) Septic Tank: se tic tank stancesfrom l nee eitted�I--IC ....Distance from found ion-.."�G-a-..-.--Material-"..��G:. )��i uid de th .. �� ...... . Capacity. (� No. of compartments.--.--- �'r-. q p �- 5P Size Disposal Field: Distance from nearest well.......... .... Distance from foundation__-....... _---....Distance to nearest lot line................. ❑ ,Number of lines ........... ......... .Length of each line.. ......... .. ...........Width of trench -------...-_-..................... ' . Total length -----------•-••---------••--••-------•- Type of filter material._. ........... ....Depth of filter material_...-- _" ....._--•_-- 9 Seepage Pit: Distance to nearest well_._/,�_/.-Distance f om f undation,��..Q__�__..Distence nearest lot liner'f-d6.�"• Linin material. __ -- YJiameter...... -._.-Depth. �. .. ............. t Number of pits. ....r�- g YCesspool: Distance from nearest woi4.................Distance from foundation .-......- ......Lining material__ ------ ---"- ---"- Size; Diameter.. ............ ...• •• - -............Depth--------------- ---------- ----------- --- ----Liquid Capacity_ ..-------•---•..-.._ gals, 1 ❑ Privy: Distance from nearest +yell......_ .....Distance from nearest building_.... ----------------................ O .._- .... .................. . . __. . 171 -- Distance to nearest lot line......... . ........... ....................... --•--•-•-•--•-- .............. ..............._...-• \ r Remodeling andlor repairing (clescribe):.............. .............. .. ." " •-•--•-- ----------------•-•--•-•--•.._..._._._...--- I .......................... ..........----..._..-•-------...-------............... ••---•---- .................................. - - ...- .....-...._ rda a - --• - _.__.__u - \ I hereby certify I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stataw 'and rules and regulations of the San Joaquin Local Health District. .___.. ...(Owner and/or Coniractor) (Sign ) 2 ---- is - �-. . .. .. - - (Title)......e,4 (Plot planBy-, s owing size o lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY................... .... .... •••----•- •---•--------- DATE... cti"------. REVIEWED BY.------------ -..._.--.-- - _... ._......._._ DATE.... ...... . ..... .._.......--.. BUILDING PERMIT ISSUED. ----- •--------------• ...... ......................... ................_-..... ------ -- DATE. ............... Alterations and/or recommendations:..... .......... ..- . .. . --- ........... - -- ...-.-. -------•-- .. .-------•------• - ............ ,� :._. rc�....... "�.......:..::: . ............--•.............. .... . . . .... FINAL INSPECTION BY:... ".__S... . ....................... ..._-.�.A Date. ._- .... ' ~ �. ._..-........... ........ SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street s14 North "C" Street 130 South American Street Trac California Stook+on, California Lodi, California Manteca, California y. Er-9