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^ � ir APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) // Date Issued --/5--3_ 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 No. 549. JOB ADDRESS ANDLOCAT ON___ � - ------- ------------•!----- Owner's Name------- ------ - -------- ---- -- ----- Address..-0 ------------------- . - TP ------------------------------------------•-- --•----- Contractor's Name----- r ( _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court Phone._Other Number of living units: ____k/`Number of bedrooms _/- Number of baths - ❑ Motel .❑ Other ❑ Lot size _____ ,.7 r / �` Water Supply: Publics stem --- -- ------- Y Community system ❑ Private ❑ Depth to Water Table _!;/Oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ AdobeK Hardpan Previous Application Made: Yes E] ❑ ❑ No New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: No (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:/ Distance"from nearest well_-_Distance from foundation__/5°� No. of cot artments---- Mater �` ' h .&ar-------------Size_g��r- "' � -----------•---- ----------- Liquid e�`�''r� , ° ' Liquid depth------e Q_ _ - �:--_____Capacity Dis osal/Field: Distance from nearest well_ _-Distance from foundation___ Number of lines-------- Len Length of each line____-_: _ p ----R47Distance to nearest lot line-____--_-_-,. g - ----- ---.Width of trench.-----Z-5/__ Type of filter material _ Depth of filter material __._��" -- Total length - -------- ------ See e Pit: Distance f nearest well_._--_Distance from foundation__- ..._--Distance to nearest lot line__ Number of its__._._ ._ ----------- Cesspool: P ------._.Lining material__$_'r--R�.Size: Diameter------ f� h-. ----------------- Distance from nearest well------------------Distance from foundation-----------__'____.Lining material_____________________ ❑ Size: Diameter--------------------------------- Depth ---------------- ------Liquid Capacity - -----------------------gals_"ti Privy: Distance from nearest well________________ Distance from nearest building E1 Distance to nearest lot line____ g--- ----------------------------------- ----------- -- --- -- -- ----- Remodeling and/or repairing (describe)- --------- ------------------------------------------- -- 3 -•------------•-----------------------•---------- -------------------------------------•------------------------------------------•-- ----------- I hereby certify that I have prepared this application and that the'work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. y -{ (Signed)--------------------------- ------ ------ - _. -____.(Owner and/or 'Contractor BY:-------------- - - - --------- •- Title _ (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., canbe )lacedrs� - -- -- -: -- P e side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.__ -_--- __.--_--_ REVIEWED BY DATE_ ---------------- - - ------------ - -. BUILDING PERMIT ISSUED------------ ---------------------------------------------------- -------- DATE--- - ----------•---------------------------------- -------------- Alterations and/or recommendations______________________ ------- ----------------- DATE------ �-•------------__ --------- ------------------------- ------------- _- T FINAL INSPECTION BY:.___ ,�L--- „ Date. _..Z ---- 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 / ✓