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(0 APPLICATION FOR SANITATION PERMIT Permit No. ._. a._7.. (Complete in Duplicate) ' 'Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. ` .—This applicatiomis made in<compliance with County Ordinanc No. 549. 10 7 JO 'ADDRESS D'LOCATiON o 2-? o ------ ----- ------ - -- Owner's Name--- -- — -----�------- - --------- - -- -- ------------------------ Phone_`^" /Go: ,-•- .Address___...__ 49 3 ----- Contractor's Name - -------------------------- _________ __ -----------------•---- ---------- --- ----•---- ----------------•-------------•--- .--------------•--- Pone.-----•-•--•---••-----•-•--------•- .... Installation will serve: Residence Apartment House Commercial ❑ Trailer Court ❑ Molel ❑ Other ❑ Number of living units: - R) umber of bedrooms_ Number of baths _� __ Lot size _ , Water Supply: Publics stem Community system ❑ Private ❑ Depth to Wat&r Table __ ft. Y --------------------------- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Previous Application Made: Yes [—] No [E]No I/ New Construction: Yes , No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic Tank or cesspool permitted if pubic sewer is available within 200 feet.) ; Septic ank: Disfance from nearest wefQl isfance from ound-tj�n__._/_19 Mate i�nl- - --------- - No. of compartments----------- -- --E•___Y.Sizef0 g� '� Liquid efth--------�- -------- --Ca acit L� Dispos Field: Distance from nearest we I_.__6!_ p y_ T- istance from foundation.- ' -- Distance to nearest lot li _ _____ Number of li _-_ -Length of each Iine__L-�_p--�-•��-----Width of trench.-_.___��f t - Type or filter me, ri '" Depth of filter material___._ _ _ _ --� = Total length- ------------- SeepagePit: ,. ,- Distance to nearest well-.--------------------Distance from foundation-------------------- Distance to nearest lot line_-___._.________ ❑ Number of pits---------------------4Li�in material----------------------- .. 9.,. ,,., Size: Diameter------------------------Depth---------.-.------ - ------------ Cesspool:p Distance from nearest well _ ____._ Distance from foundation ______________Lining material-------------------------_ ❑ - Size: Diameter-- ------------ -- ----- Depth-.---,-----:----- --- --- Liquid Capacity _.------_ ---gals rrvy; Distance from nearest well__:____________________---_----- Distance from nearest building ❑ Disfance to nearest lot line__ g "=`-� �- _ _ -------------•---------------------------------------------------•--------- Remo lin and/or repairi _______ 11�.t.. ------------------------ ----- ------------ ------- -'-•-•--•-------•-----------------------------•---•------•----------------------------•---•----------------------------- ------------------------------------------------------------------------------•-•---------•--------------- 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. E - (Signed)--- �L'; a ----------- " ------------------------------------------------------------------------------ -------(Owner and/or Contractor)BY:. --------------------- (Plot plan, showing size of lot, locaf'on of system in relation to wells, buildings, etc., .can(bel placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. REVIEWED BY i ___.__ ------- --------- DATE. ' ---•--- ------------------ ---- DATE.__ BUILDING PERMIT ISSUED-------------- + -------------- Alterations - - -----------•----------------------- --------•--------•------------------------------------•------------------------ DATE_.----- - Alterations and/or recommendations:___.___--____..__-- ' ------------------- ------------------------------------------------- FINAL INSPECTION BY:------------------------------------------------- ------ 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 ES-9-2M 10-52 Revised W-2100