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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued# ----------- ---- ` Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein desr-,ibed, This application is made in compliance )J with County Ordinance No 549. -• . / j - --------------------------------------•------------ JOB ADDRESS- AND LOCATI N.--. � �-----------// Phone.�Owner's Name----- - ----- ------- -� Address----------- = ai• — ----------------------------------------------- - --- --------- - �Cont - • -- _____ Phon `�� ---------- Installation ractor s Name___ - - ---- Installation r G will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __.l-__ Number of bedrooms .,2-- Number of baths -__ --- Lot size .___-c �____��___�__2- ------------------ Water Supply: Public system &-Community system ❑ Private ❑ Depth to Water Table it. _ Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay E] Adobe ardpan ❑ Previous Application Made: Yes E] No [5--Id�w Construction: Yes ❑ No ��--- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) pt' an-- Distance from nearest well.. ...........Distance from foundation--------------------Material -.__----...---.-_-.---_._-____--_---_----- -.. No. of com artments--------------------------Size--------------------------------Liquid de th------------------ p R --------------------------Capacity-----------•---------- Disposal Field: Distance from nearest well-_..............Distance from foundation--------------------Distance to nearest lot line_--___-__------__ i Number of lines-----------------------------------Length of each line------------------------------Width of trench---------------_-------_----------- - Type of filter material---------------_-----____Depth of filter material----------............Total length--------._-._-_.___._______---___ le / Seepage Pit: Distance to nearest wel d--.Distance om fouu dafron---.lr------- Distance to nearest lot line-__�- ---- 1 [4,—r 'Number of pits--- 1--------------Lining material__ �r/�.--Size: Diameter_.s�___..................Depth__. __---_--.-__----.____- , Cesspool: Distance from nearest well------------- from foundation--------------------Lining material---.---------------..-._---_---__-_-. ❑ Size: Diameter--- -----------------------Depth------------- --- •-------- ---------------------Liquid Capacity----------------------------gals. ' Privy: Distance from nearest well__--- ----- -----------------------------------Distance from nearest building-------------._----_----___--_._-----.-.-. ❑ Distance fo nearest lof line--------------------- ----- -------------------------------------------------------- --•------------ --------------------------------------- C C. 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. (Signed)---&_4 --- (Own - ar Contractor) By: f� - - -----.. -G- ."-s-r+ - -----------------`----- (Tit{e} ------------- ' (Plot plan, sho irT'ng size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- DATE--- ._ REVIEWED BY --------------------------------- _.. _ DATE ------------------- ------- - - ------------- - - BUILDINGPERMIT ISSUED--------------------------- ---------- ---�.-----------------------�----------------------- DATE--- ----- ----,--- -----•------ Alterations and/or r on�m tions:. -------------------------------------- `� ------------------------- ------------------------------ ------ -. '-- ----- ---- ----`�-�------ ,. ------ - ----------- �b - -- -- ---------------------------------------------------------•-------------------•----------•------------------------ - ------------ ---------------•------------------------------------------ ------ - - --------------------------------------------------- ----------------•---------------------- ----------- --------•- •-------------- FINAL INSPECTION BY:....` �_ Ls--------------_- ------------- 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 14544 ATWOnD 12-54