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APPLICATION FOR SANITATION PERMIT Permit No. _-__-ref, _ Z (Complete in Duplicate) ` �- Date Issued ___/-9-1s�_ Applica+ion is hereby made to the Son 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. 549. "A= .j 0 P JOB ADDRESS AND LqCATION_-.QY.._/- 1O_oL-1- 1 3 O _ �'o -- Owner's Name. - --------•------------------•-- - - -- ----- --•- --- --- ---- - -- Phone--------------------------•-------- - ------------------------------------------- Address____ _e_ •-- A ---------------- - --------------------------- Contractor's Name -- ----------- ----------------- --------------- ----- Phone ----- --- Installation will serve: Residence ar ment House E] Commercial ❑ Trailer Court [IMotel ❑ Other ❑ Number of living units: --- Number of bedrooms ---2 Number of baths .1-__ Lot size _____ ___ ------- ---- ----------------•- Water Supply: Public system ❑ Community system ❑ Private J } Depth to Wafer Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam P§--1G`(ay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ew Construction: 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 well__,5.�0-. Distance from foundation--. � m _ No. of compartments------- --------------Size_---4---r1(---V-0 V-0_-Liquid depth_ t ---- Capacity_.-_1610. _` Disposal Field: Distance from nearest well_4;or_._.-_Disfance from foundation_-___/_ �. / � Distance to nearest lot line___..W.D�__. �upmber of lines-------/__------ r-_------Length of each line----7-_0-_r---------._.Width of trench----z.Y• r. - T e of filter material___LZ_ ______________Depth of filter material_-,�-8- _.___.--Total length------V 0 _ Seepage Pit: Distance to nearest well_rA0a_'-------Distance from foundation____,S__0_'---_Distance to nearest lot line------------------ Lining ' Number of pits.--- '- materiai,BL ..A-�.-_Size: Diameter_. , ---_'---------Dep#h----2— P-'----------------- ' Cesspool: Distance from nearest well-----------------Distance from foundafion-----.------------..Lining material_--._--__----___--..___-.___---_____. ❑ Size: Diameter------ -------------------------------Depth-------------------•------------- - --------- ----Liquid Capacity-- ---------- -------------gals. � Privy: Disfance from nearest well-----------------------_-__.-----------_---_--Distance from nearest building.___.__.__-__-____-_____. _. .❑. :Distance to nearestlot,line - : . .�� -------- i ---------- -- - ---, Remodeling and/or repairing (describe):------------------------------------------------------------------------------------ -------------- , ---------------------------------------•---------------.-------....--------- --------------------------•-•------•------------------------•---•--•-•-------------------------------------•----•----------•-------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with Sart Joaquin County ordinances, State jaws, an_d rules and regulations of,the San Joaquin Local Health District. , (Signed)_... Contractor) B : y s: -a-* " --•--------------------------- ----•------------------------(Title)--------------------------------------------- _____ ____ . (Plot plan, showing size of lot, locafion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ DATE.-------- - ` REVIEWEDBY------ -- ------------- -------�------ -------------------------- ------ ----------- - y�--- ----�----- ------- ------------------------------------------------- DATE----------------- ---------- lJILDING PERMIT ISSIiED-__..________________ ------------------------------- ------------------------------------------------------------------------------. DATE-- --------------------- terations and/or recommendations:_-__`__------------- -------------------------- -------------------------------------------------- FINAL INSPECTION._By:------------ - Date 1 ----------------1------3 =_......... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 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 145446 ATWOtlP 12-54