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APPLICATION FOR SANITATION PERMIT Plermif No.,2.._ Z�f ; /�...- (Complete in Duplicate) Date Issue /2 o�SV 1 d -- 1 -- 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 complian cpwith.Coun rdinance No 549. JOB ADDRESS D L C ION--- -------------- ----- ff� -=-=--- - ------ -- ----- ----- --- ------ Owner's me-- �� {� ---- hone--------------------------------•--- k �.- ! ` - -------•------------------------------------•-J------------------.------•---------_------------_-----•---.- Address---------- ----------��.--••�=------�---•-- -----.-. -:-- :=-•----- _-- I Contractor's Name------ .__-.----- --- Phone----------------------- - - ----- ---------------------------------------------------------------------------------------- Installation will serve: Residence ❑ 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 _______ ft. . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoVM0 Clay Loam E] Clay [I Adobe ✓[)Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f ublic sewer is available within 200 feet.), Septi ank: Distance from nearest well Distance from foundation✓►� _______.Material____ ______ _____ No. of compartments-------- - ---Size------1-----------------------Liquid depth--------------------------Capacity---- a Dispos Field: Distance from nearest well___ _. _ istance from foundation___ _�.__.----Distance to nearest lot ling Number of lines_________ - e Length of each line____________ ___, q _Width of trench _ __--_ _ ��{{� c� Type of filter materi ik----- ---Depth of fitter material_ __ ---Fes+-------Total length--.__---a-__________________________. r ------- ..DistancA to nearest to lin Seep a Pit: Distance to nearest w II o � D�stanc f jo oun at�o ..__ j Number of pits=----- w I material-_P _+ b: Diameter Depth f�f Cesspool: Ifistance from nearest well_________________Distance from foundation--------------------Lining material-----------.__________________...._. ' ❑ Size: Diameter--------------------------------------Depth-----------------•----------------------------------Liquid Capacity----------------------------gals. Privy, Distance from nearest well----.--------------------------------------------Distance from nearest building------------------------------------------ 171 Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- e Jelin and/ r re airing {des robe): Jf.- -- --------- . ------------- ---------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County E ordinances, State laws, and rules and regulations the San Joaquin Local Health District. (Signed __ ---- n1J (— +�s ":,•-------------------------- ------------------------------------(Owner and/or Contractor) --------------------------------- Y. - - (Plot plan, showing size of lot, location of system iin,relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -------- ----------------------------------- ---------------------- DATE ' - REVIEWEDBY------------------------------- -- -------- ---------------------------------- - --------------------------------------- DATE - ------------------------------------------- i BUILDING PERMIT ISSUED--------- - ------------------------- -------- DATE----------- ----------------- Alterationsand/or recommendations----------- --------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----- - •-------------------------------------------------------------------------------------------------------- --------------------------------------------------I-------------------------------- -------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------- FINAL INSPECTION BY: ._________ __ Date_ ----------------------------------------- ------ -------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South AmoriGan Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California a ES-9-2M 8-51 Revised W-2100