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it APPLICATION FOR SANITATION PERMIT Permit No..,-?,Al-------------- (Complete in Duplicate) Date Issued J) Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This P 6 plication is made in compliance with County Ordinance No 549 , JOB "ADDRESS AND LOCATION----- jc� ---------------------------------------- Owner's Name------------------------------------ 7' Ej�- ------- Phone_ Address----------------------------------------------- ----------- ....... -------- ------Phone_-------------------------------------------- I "I ----------- .../9C -4-1-1------------ Contractor's Name--------------- --------------- - Installation will serve: Residenpe [g Apartment House Ej Commercial L] Trailer Court [] Motel 0 Other [I 0 Number of living units: __l__ Number of bedrooms __t__ Number of baths __/--- Lot size ----------,/_ ----____ Water Supply: Public system Community system El Private E] Depth to Water Table O ft. Character of soil to a depth of 3 feet: Sand E] Gravel n Sandy Loam Ej Clay Loam L] Clay n Adobe Pgr Hardpan ❑ 'K Previous Application Made: Yes L] No New Construction: Yes Ej No L] TYIPE�iOF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------------Maferiai----------------:-------------------------------- bNo. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity------------------ I Disposal epth--------------------------Capacity------------------ Disposal Field: Distance from nearest K well,41offa-Distance from founclalion__A_i� --Distance to nearest lot Number of lines______I----------------------------Length of each line---- __----_-________.Width of --- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepa'ge Pit: Distance to nearest well----------------------Distance from foundation----------------._Distance to nearest lot line_________________ 0 ine----------------- Ej Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-_--------------_------_--------- Cesspool- Distance from nearest well_________________Distance from foundalion-------- ---------- Lining material---------------------------------------- Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well_____._____________________ _______________:Distance from nearest building------------------------------------------ ElDistance to nearest lot line------------------------------------------------ --------------------------------------------------------------------------------------------- Remodeling and/or repairin be):_____f---- ---------- ----------------------- .,,(descri ------ ------- ------------- ------I- - --------------------------------------------------------------------------------- ------------- ----------------------------- ---------------- ------ -------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------f------------------------------------------------I------------------11------------------------------------ I hereby certify that I have,-prepared this application and fka6he work will 6e done in accordance with San Joaquin County ordinances, State laws,-an regulations of the San Joaquin Local HAIA District. rules and ------- ---------------- _J.G_�wnermwmd or .... ..... (Signed]— -------------------- -------------- -------------------- ----------- ,;Contractor) ---------------------------------------------------------- ------------ (Plot plan,,i�o4ing -size of lot, location of system,n re afion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY W --- DATE , '. .1� ---- REVIEWED - ---- ---- REVIEWED BY---------------------------- DATE -- -0- - - --- - - --- -- -------------------------------------- BUILDING -----------------------------I-------BUILDING PERMIT ISSUED------------------------------------------------------------,----------------------------------------- DATE-------------------------------------------------------------- Alterationsand/or recommendations:-----------------------------------------------------------------------------------------------------------------------------------------------------------------L-----------------:-----------------------------------------_---------------------------------------------------------- -------------------------------------------I—,-------------------- --------------------------------------------------------------------------------- --------------------------------------------------------------------------4--------------------------------------------------------------- -------------I----------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------I--------------- ------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ---------------------------------------------------- EI FINAL INSPECTION BY--------W---V__H--------------------------------------- Date------ ------------------------------------------------ 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 E5—'9-2M 8-51 Revised W-21.00 :r