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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) � Date Issued •�__-__�-_`_f-_�O� Application 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,4vith County Ordinance No. 549. 233— V&o -I2— JOB ADDRESS LOCATION -f�--J _�. - Owner's Name ... Wit'-__ ----- - C� ----- ---------- -- ne----------------------------------- Address----------- '�= r ---- --�)--------- Contractor's Name----- ••- ;J- -� -------------------- Installation -- r Installation will serve: Resi7ence ❑ 'Apa merit House Cg+nmercial ❑ Trailer Court ❑ Motel ❑ O er ❑ J----Number of living units: _I----- Number of bedrooms ________ Number of baths __f_____ Lot size Water Supply: Public system ❑ Community system E] Private Depth to Water Table _ _ ._ ft. I Character of soil to a depth of 3 feet Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes E❑ No%D� New Construction: Yes No ❑ FHA/VA; Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weli__4-----Distance frm foundation----- -----.Materal- - ---- --------a-t--i-t- No. of compartments_____ ____---.__ Liquid de th-___"di -----Ca --�- p Y Dispos I Field: Distance from nearest well _.3.--_.Distance from foundation----O----------Distance to nearest lot line_ Number of lines Length Length of each line----- Q______ Width of trench__ __ __ Type of filler material-1_r_-_ ._Depth of filter material----- Total length---___' _s ________________________ See ge Pit: Distance to nearest well-------4__u'�-Distance from foundation____ � _ DQis# tet nearest lot line_��t ,.. ?� �iNumber of pits ------------L terial----------------I"• +�: efer- 6pfh--------81 -Cess ool: Distance from nearest well-----------------Distance from foundafion--------------------Lining n9terial_________-_------___________-______ ❑ Size. Diameter--------------------------------------Depth----------------------------------------------------Liquid_Capacity------------------------------gals. Privy: Distance from nearest well-----------------------------------------------Distance from nearest building------------------------------------------ ElDistance to nearest lot line- -----©-------------------------------------------------------------- ------ ----------------------------------------- Remodeling and/or repairing (describe):�� -----f__" ---- - -- - ---------------- -- - -- ----- -- ---- ------------- --- ------------ -- - ------ - - j//_- - --------- -----------------•---�--=-•---- --------------------��- -•----- ----6"44-------------- - ---- -- ---------------------- j --------------------------------------------------------------------------------------------•------•--------•-•----------------------'------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin CounR-14 ordinances, State laws, an ules and egulations of the San Joaquin Local Health District. I (Signed).:. ,.� -- ---j-------------------------------------- i _.__.____.(Owner and/or Contractor BY=--------------------`-------------------- ----- '----------------------------------------------------------------------------------(Title)---------------------------------------------- --------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). y ! FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-------------------------------------------------------------------------------------------------- DATE REVIEWEDBY-------------------------------------------------------------- --------------------------------- ------------------------- DATE----------------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------ Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------ ---------------------------------•---•--------------------•-------------------------------------------•---------------------------------------------------------------------------------------------------------------------- Date FINAL INSPECTION BY-------------- -----------Lo_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Sfreat Stockton, California Lodi, California Manteca, California Tracy, California ES---9---2M , Revised 1.57 P.P.CO. I l