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APPLICATION FOR SANITATION PERMIT Permit No. .._ �J---3 (Complete in Duplicate) _ Date Issued Application is hereby made to the San Joaquin,Local Health District for' permit-to construct.-and-install the wwo1r herei�desc�bed. This application is made—iii iilia'rice with County Ordinance No. 549.E JOB ADDRESS ANq LOCATION__ a " ' Owner's Name------------- -- - -ter- r ` ' !<• - Pone ---------------------------------------------------------------------------------------- --- [ Address ` Contractor's Name ----- Phone-•-- Installation will serve: Residence ® Apartment House El Commercial [I Trailer Court E] Motel ,❑ Other E]units: Number of living � Number of bedrooms +�-- Number of baths -A! Lot size ---- ��--r.-_a9Z4r__,��QB _ Wafer Supply: Public system'❑ Community system ❑ Private X Depth to Water Table Jft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Z Clay Loam ❑ Clayr❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ��f (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__/34----_-Dista c fr E �foun------atonl_______.Mate91____ - --4- iLiquRd depth------- ---------------Ca ac_it-Y-_-_--No. f comartments.-.--- �` - Disposal -f------__ f-- Q-- -- Field: Distance from nearest well --.Distance from foundation _ foundation_____ Distance to nearest �lot-�line -'-_ -_-_- _ Nm of lines-------- � -� ___. __ th of each line__-_-____ Width of trench -----_ Depth of filter material_____ - --- --Typa Eof filter materia_l._ ____ _ length-,-------- ---------_ eepage Pit: Distance ` to nearest well_.___--____ _.__.._ Distance from foundation____________________Distance to.nearest lot line ❑ Number of pits...-___'---------------Lining material-----------------------Size: Diameter-----------------------Depth--------- -�----------- ------ s Cesspool: Distance f:-om nearest well_________________Distance from foundation__._-_____.-------Lining material__.__-.__-----_____---____--- ------- . +ie Diameter.. e;-,:-_e;�.- ------ -- -Death; --- ------- --- Li uid Capacit.Y Privy: Distance from nearest well ❑ Distance to nearest lot line -----------------------Distance from nearest building ---- ----------------------------------- --------------------"----------•---------- ----------_------- Remodeling and/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, afe laws, and rules and egulations of All'n!Joa,4uN Local Health District. (Signed).. �.� ----- --_--- -------- ------------------- ---------------------------------(Own and/or.Contractor) Plot Ian, show' size of lot, location of system in relation By:-----------__--------- ----------- ---- ----- ----- ---- -------------------------------- ------(Title)----------------------------------------------- ---------------- P g on to wells, buildings, etc., can be placed on reverse side). FOR DE , MENT USE ONLY Jill APPLICATION ACCEPTED BY_________________ ..__- __-, ll .--__ DATE4 REVIEWED BY. , -------------- BUIL ---- _---- DATE------------- • - - ------------------------- ---------- DIN PERMIT ISSUED ------ DATE_.- Alterations and/or recommendations:__--------- ----------------------------------------•-•--------------- ----------- r ---- •-- ----- ` --- I--- ----------- ------k -------------- : ---- FINAL INSPECTION BY: ......... -.. --- Date-- SAN JOAQUIN LOCAL HEALTH DISTRICT 13D South American Street 300 West Oak S+rsat 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9--2M 10-52 Revised W-2100 Sill