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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued .---- --�- �3 7 Applicafion is hereby made to the San Joaquin Local Health Disfrict for a permit to construct and install the work herein described. This applicafion is made-in compliance with County Ordinance 549. JOB ADDRESS D CATION--------- .- . ._ Owner s NaP ane me_._ f� - --- - --- --------------- --- - ------- ------- Address_._ --------------------------------------------- -----------------------•------------------------------------ Contractor's Name____________ r Phone---.7___ Installation will serve: Residence Apartment House Commercial ❑ Trailer Court (] • Motel Other ❑ Number of living units: .-- t_-_ Number of bedrooms -_ Number of baths - qq v k Lot size .3o4-f�--/_ Water Supply: Public sstem - - 1 pp y' Y ❑ Co-Communify system ❑ Privafe� Depth to Water Table [� Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ CIQft i Previous Application Made: Yes E:1 No New Construction: Yes No ❑ Y ❑ Adobe Hardpan (3 ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic Tank or cesspool'permitfed if public sewer is available within 200 feet.) Septic T k: Distance from nearest well------ from foundation_________----------- No. of compartmentsMaterial r -------------------- -----Size--------------------------------Liquid depth--------------------------CapacitY----------------------- f Disposal. i d: . - Distance from nearest welt --- ----Distance from foundation_------------------Distance to nearest lot line----.-_ Number of"lines---•-- Length of each fine -_--__._: ----------------------------- width of trench.----_.__-___--- :Type of filter material---------__- Depth of filter material Total length_.--- -------- i' ' i Scapa e +t: Distance to nearesf well-----. ___----Disfance.f rr fo ation___ Number of pits_---,------------- ,�y •-----D'r tan i�to nearest lot line------------ I Lining material_ _ __ __ _ -_-.Size: IJiamefer_ Cess ool: Deptn- rfl---------------- p Distance .fi•om.nearest well--------------- Distance from foundation-__----_-_______ ' --. Lining material------------ ❑ Size: Diameter--- '---------- ----- Depth---------------- ? ------Liquid CapacitY----•------- -------gals. a Privy: - Distance from.nearest well----- -----------------------------------------------------------------------Distance from nearest building-_--_-.__--_--- ❑ Distance to nearest lof line---.=-: -------------- - I f r Remodelin or pairing (describe):__.- ---- ------ +----- -•-- ------------------------------------------- -----------•------------•------••-•-•-------•----------------- ------------------------•------------------------------------------------------------ -- ------------------------------- •---------•----------- Ihereby certify that I have prepared this applicafion and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ions of the San Joaquin Local Health Dist ricf. } Si ned - g --- ----------- ----- BY=--• --•-------- -- -- -- (Owner__.(Ow a or Contracfor) (PlT ----•--------- ---------------------------------------------------------------(Title). ......of plan, showing siz of lot,.locafion of system in relation to wells, buildings, etc., can be pl on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------- --------------------------------- REVIEWED BY DATE ----------------------- ---------- DATE__-------•---- UILDING PERMIT•ISSUED-----=-------------------- - ----- -- ---- ---------------------- --------- terations and/or recommendations- _______________ __ _ --�-•--�---�---�`-�- - ---------. DATE------------------------------------------------------------- i ----- --- ---- --------------------------------- "7F 4 ---------------------- -------------------------------------------- -------------------------------------------------------------------------------- ------------------------------------------------------------------- ------------- --------------------------------'- FINAL INSPECTION BY-------------V'- ✓A-Zc --------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 Soufhr.American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100