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T APPLICATION FOR SANITATION PERMIT Permit No. ----- -- 1 (Complete in Duplicate) Date Issued ---1--------- Applica{ion 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 with County Ordinance o. 549. JOB ADDRESS AND C ION------ _ ----- ----- - ------- -- ------ -----------•---------------- --------- -------------------------- Phone_,, ..{��---------------- Owner s Name----- --------------- -- -- -- ---•----- -------------•------------------------_----- Address ------- --.---- -----• � _ Address------ --- -- - --- - --- Phone, f � Contractors Name----------------------------------------------- --------- installation will serve: Residence ,Apartment House ommercial ❑ Trailer G+r# ❑- Motel ❑ Other ❑ ' 1 __- umber of baths _/-_. Lot sizeCl --f � Number of living units: __�___ Number of bedroo Water Supply: Public sYstemx Community system — rivate ❑ Depth to Water Table ft. r of soil to a depth of 3 feet: Sand ❑ Gravel El Sandy Loam El Clay Loam El Clay ❑ Adobe, Hardpan F1Characte P �� Previous Application Made: Yes ❑ No New 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• Distan a from foundati?n-��--_____Material________________-_--__----- ---_-_--.------. p� No. of compartments__Q„r J-- . -Size .,1 ��.,�.�-Liquid depth_, --- -- Capacity P'C s - Of to nearest lot l/ine__..--_---- Disposal Field: Distance from nearest well/lf��---Distance from foundationr Width of trench____ Sa-------------------- Number of lines-------/--------------- Length of each line---- - y .4 Type of fi4ter.material __ __ ____-Depth of filter material____/�_.___ ----Total length__..._____ -.•------------ Seepage Pit: Distance to nearest well--------------------_Distance from foundation--------------------Distance to nearest lot line--_----_-___-_--_ \ --Linin material-----------------------Size: Diameter-----------------------Depth--------------------------------- �\ ❑ Number of pits--------------- ---- 9 , k V` Cesspool: Distance from nearest well_________________Distance from foundation._.._.____.__.___ _Lining materia___.___..._________.___________.��5. `n ❑ -------Liquid•Capacity----------------------------9 V1 Size: Diameter------ ----------------------- -------Depth----------------- ------------------------- Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------- ------------------------------ ❑ Distance_ to nearest lot-line-------- -------- --------- - ---------------------I------------------•--•---------- e ` -------------•------=----•------------•-------------------------•-- Remodeling and/or repairing [describe}-- -- -- --------- ----- ------------------•------•-----•-------•-- ------------------•------- -------------- --- ---------------------- --------- ! hereby certify that I have prepared Phis application and that the work will-be done•in accordance with San Joaquin County W, ales/and re ulations of the San Joaquin Local Health Districtordinances, State9 (Owner and/or Contractor) t --.... i ------------------------ (Signed) ,f E By:.---------- ► � ------------------- -----------------------------------{Title)--- - ---- (Plot plan, showing size o ot, location of system in relation to wells, buildings, etc., can be pl ed o averse side. FOR DEPARTMENT USE ONLY DATE '—__ ----------------- APPLICATION ACCEPTED Bl� DATE__ --------------1-1---------------------------------- REVIEWED BY---------------- ---. -- r DATE BUILDING PERMIT ISSUED------------------------ 4!\ ------------------------------------------------------ i --- ----- -------I------------------------------_------------- ------------------ Alterations and/or recommendations----------------------------- -------------- -------- ----------------------------------- Date----- ---- ----- -------------------------------------------------------------- FINAL -- - ----- -------------------------- --------- FINAL INSPECTION BY----------------------• 4 SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 sycamore Street 814 North "C" Street 130 South American Street TracCalifornia Stockton, California Lodi, California Manteca, California y. k ES-9-2M ; Revised W-2100