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APPLICATION FOR SANITATION PERMIT Permit No. ------- (C 5.-9. _ (Com lete irlruplicate) J J t 1r !1 Inn Q y�• cl[ K �•, S a A-OZ Date Issued10 0 of Applica+ion is hereby made to the San Joaquin Local Health District for a perm;} to construct and instal] t e wo k he 'desc ib d. This application is made in compliance with County Ordinance No. 549: J AD RESS AND I LOCATION Owners Na : -- ^- �--l-�-v----------u--- --- -- --------•-- ----------- - ---- -- --------------------- ----- - e�q Phone -- Address------- --r --- A � h — Contractor's Name------- e � ,--------------------" Phone ---=-------------- { Installation will serve: Residence A artment House ❑ Commercial J] Trailer Court [jMotel ElOther ❑ Number of living-units: __L Number of-bedrooms .5. Number of baths -_/__ Lot size __-�_ Wafer Supply: Public ysfeni'❑'"'Community system ❑–Private TrDpfh to Water'Table Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan [ ! Previous Application Made: Yes ❑ No 93"" New Construction: Yes 2No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank.or cesspool pe-rmifted if public s wer is available within 200 feet.) __ : Septic Talk: Distance from nearesr well r � Distance fr foun ation___--l-d_~____.Mafe ial--_---_ _' __ -- Lf No. of compartments--------- ----------Size- - --- - rr Liquid �th �--- --------Capacity-------------------- Disposal Field: Distance from nearest weli...Cp-d Distance from founds ion- -___---- --- r ___Distance to nearest I 1; ��_____--- [ Numl7er of lines-._.-I .-- -�- ---_ - --rf Length of each line--- ---____-- _.Width of trench/- /-- f, 1 -------" * it Type of filter mater---�-�---- -Depth of filter materia----._-/__�-____Total length--_--,� --------------- --- Seep e Pit: Distance to nearest well__— __Distance from foundation--- r r �/� ,�--_--. ist to nearest lot ine.-__-__-�`.�___ p +-- -----Linin ma ��" r ' : Diameter_/d_1----De th_ - i P r p y Number of its. -- well________________Distance from founds} ' y Lining �_ S. Cess ool: Distance from nearest1well earest ion..... -___.--- Lining material__.--__-- _ ❑ _ Size: Diameter--- i I M , f rivy: Distance from nearest Nell------------------------------------------------Depth r� Distance{rom�nea eat IacitY----------------------- P gals. A, Distance to nearest lot I;ne.................... 'q building ------------------ R ----------------------------- emc, eling and/or repairing [descri€ e):-[-_- -_--_. ------------------------ --------------------------------- -- ; i -------------- ---------------------------------- -------------------- ---------------------------------------- ---------- "i.- -------------"'-----------•------------------------b`------"------•---•-"'-------------------------------•-------------------------------------------•------------------.---.------__--..-_----------._ I hereb _•cerfify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,'}, tetlaws, and rules and'regulations of the San Joaquin Local Health Disfrict. [ (Signed)----- p A- -------- ----- ------------------- ,I T (Owner and/or Contractor) j 13 Title - _ y [Plot plan, showing size of lot, location of s sfem in relation to wells, buildings, efc., can be placed on reverse side). i ;... FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_ ----- DATE x `! . EVIEWED BY --- -------- -------------- DATE BUILDING PERMIT ISSUED----------- - ------------------------------------- ,- -- --- DATE-..----------------•--------- Alt orations and/or recommendations.-_ 4 N- -------------------------------------•-------------- ikIt ------------ ------------- ----•----,--------------------------•--------------- ------------------------------------------------------ ------------------•----------- --------------- FINAL INSPECTION BY:... _ - •.- Date_ 9 v� 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 t9-21v1 Revised W2100 ,#'