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APPLICATION FOR SANITATION PERMIT Permit No. .l'o.:3.. (Complete in Duplicate) Date Issued -_7--1 _sq Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the�"orkahere' �lesr�rib d. This application is made in compliance with County Ordinance No. 549. rJ= ��°3 -1�Q-2� `fi d/71 �f Z 1 M. 0"6*<t O*'�f re JOB ADDRESS AND LOCATION___.___ __ _______ _...______ ."__ g ' y _1� ,�. '�............. 1 ' Owners Name-------------------------- - ` -----�--------------------lu -rJ--._- Phone /� - - ------- ` Address---------- ------------------------------------------- --•- -- -- �--- Contractor's Name------------- -----• a � Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms _ Number of baths -------- Lot size -----/7-f {_____Iw{..:_____________________ Water Supply: Public system El Community system ❑ PrivateA Depth to Water Table . . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ]� No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: t _� ` (No--septic tank or cesspool'permitted-if public sewer-is available within'200 feet.) r Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material------------------------------------------------- --------- Capacity----------------------- 0 No. of compartments------------------------ -Size----------------------------- Liquid depth---------------- '111 4 __.--Distance to nearest lot line____.s _______. Disposal Field: Distance from nearest well.., Sa. _-Distance from foundation._ _ �� Number of lines____________I------ -------------Length of each line---------- -----Width of trench-.-------- --------__---- --- r� Type of filter material------ _�f P �-________._Total length___-_-..___ _ t __-________Depth of filter material_______ _ ----------------------- + Seepage Pit: Distance to nearest well----------------_-----Distance from foundation--------------------Distance to nearest lot line____.__________ ❑ Number of pits----------------------Lining material_-.--------------------Size: Diameter------------- ---------Depth- - ----------------------------- V Cesspool: Distance from nearest well_____________ _Distance from foundation--------------------Lining material------------------------------------- Q� ❑ Size: Diameter------------------ ------------------Depth-------------------------------- ----------- Liquid Capacity----------------------------gals- R� Privy: Distance from nearest-well-------------------------------- ---- --Distance from nearest building----------------------------------------- ❑ Distance to nearest lot line-- ------------ ----- -----------------------•------- ----------------------------------------------------------------- Remodelingand/or repairing (describe):----------------------------------------------------------------------------------------------------------------'-------------------------.. -------•-- -------------------------------------------------------- - ------------------------------------------------•------------•-----------------------------------•----------------------------------------_--------------------'•------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances. S laws, and r s and regulation of the an Joaquin Local Health District. (Signed ----- (Owner and/or Contractor) v. "•--- =— T; --------------- -- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-----------------------------------------------------rr� --- DATE---------- REVIEWEDBY------------------------- ----------------- ------------------------------------t------------------------------------------ DATE-------- ----------- -------------- PERMITISSUED-------------------------- -------- --------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations----------------------------- -----------------------------------------------------------------••----------- ------•---------------•-•---------_ -------------------------------------------------------------------- ------------------- Date------r__a-- --------- -------------- FINAL INSPECTION BY:.. _ - _ -.- ------------ _--------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M ; , Revised W-2100