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APPLICATION FORPermit No. . - ------ SANITATION PERMIT .(Complete in Duplicate) Date Issued ----Q--� J 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 compliance with County Ordinance.N 549 ..+. JOB ADDRESS A OC TION---- _ ._t_ - - ---- �j - --------------------------- Phone_�------7_ '0----- Address L - ---i ---- --------------- Contractor's Name:_ -- ---- ----------------------------------------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trader Court ❑ Motel ❑ Other ❑ `Number of bedrooms _ ? Number a aths _-_f_-- Lot size ._ - --------- --------------- Number of living units: ____---- Water Supply: Public system ElCommunity system ❑ Private Depth to Water Table ZZ ft. Character of soil to a depth of 3 feet: Sand ® Gravel ❑ I'Sandy Loam Clay Loam [I Clay El Adobe M'--/Hardpan ❑ \ Application Made: Yes No R/ New Construction: Yes No ❑ Previous App ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ( p Distance from nearest well --C5 0 Dista available within 200 feet.] J No septic tank or cesspool permitted if public sewer nc fro ou on_._ ----.Materi --�__ _____________________ _ ---------- Septi ank. No. of compartments =. f_: ;_ S�Liquid dept Capacity---., { Dispos I Field. Distance from nearest wel-_ '---D stance from foundation__- ,- - -__-Distance to nearest lot ine _ ---- ---- Number of lines_. _:_____ _Leng #h of each line----- - �.- Width of trench-- _-- --_ `---------jgals Type of filter materia r-�-„p } II i- e t,h of filter material---------- --------Total length----- - -�_--------A- pp gance - nce from foundation--------------------Distance to nearest lot line___-___-See❑a e Pit: Nlutmberr of pitarest wall------ Lining mDate sial-----------------------Size: Diameter-.---------------------Depth-----------------------Cesspool: Distance from nearest well-______________-Distance from foundation__--_-------..____-.Lining material_____________-____._______Size: Diameter---------------- ------------------ Depth------------------------------ Liquid Capacity � _. Prfrm nearest we -_____--_ Distance f ------------------ rom nearest building------------------------------------------ ivy: Distance o ❑ Distance to nearest lot line------ - ----- --------------------- ------------ Remodeling and/or repairing {describe)---------------- -------------------'-------------------------------------------------------------------------------•---------------------------- -------- ------------------------------------------------------------------------------- ---------------------------- hereby certify that ( have prepared this application and------------------------------ ------------------------------- ---------------------------------------- ordinances, Stat aws, and rules and ,ed this a li the Sand that the work will be done in accordance with San Joaquin County IiJoaquin Local Health District. 1 (Owner and/or Contractor) --------- By: - -------- ------ (Title)---------------------------------------------------------------- (Plot plan, showingsize of lot, location of system in relation +o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �------------ ------------- --- ---------------------- DATE ------ ------------------------------- REVIEWED BY---------------------------------- _ DATE ----------- BUILDING PERMIT ISSUED--------------------- DATE-- -- - - ---------------------------------------------- Alterations and/or recommendations---------------------=-------- - -----------•--- I ..-•------------------------- ------------------------------------------------ ------------------------------------- ----- ------------------------------ Date FINAL INSPECTION BY:__ .,/1--------------------------- � -�1 1 ---------------•----•----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Idor+h "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100