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f Permit No. L APPLICATION FOR SANITATION PERMIT u 3---�-•-- ------• in Duplicate) / 7 S3 \� (Complete 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 application is made in compliance with County Ordinance N. 549. --------------------------------------- j ` ° = JOB ADDRESS AND OCATION____ _" .-- ----- Owner's Name -- -._. Phone------------------------------------ ---------- --------------.. � �f te -- ____Address_ �` j „ Phone_. Contractor's Name------ _ - i artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ f Installation will serve: Residence [�Ap r 0 Number of living units: "-f_- Number of bedrooms .2— Number of baths ---Y--- Lot size ______Zj__---------/-- ------ Water Supply: Public system ❑ Community system ❑ Private [6"-Depfh 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: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) *7� Septic Tank: a Distance from nearest well________________Distance from foundation-------------------Material----------------------- ----------------------- ,�/�C,®, No. of compartments--------------- Size Liquid depth Capacity Disposal Field: Distance from nearest well...--__.____----.Distance from foundation___-______--_____.Disfance to f nearest lot line _____.__"_..__ Number oil lines-----------------------------------Length of each line----------------------------- Width of trench --------------- Type of filter material-------------------------Depth of filter material-----------------------Total length--------------------•------------------- r / --_Distance from foundation--___:3 ".--.Disfance to nearest lot line__l -".---- Seepage Pit: Disfance to nearest well_"-___��--"_-- �r r � --_.Linin material___ + c 'Size: Diameter---,7- --------------Depth---A: ----------- Number of pits.."------�- -- g Cesspool: Distance from nearest well-----------------Distance from foundation-:---------------"-Liquidning Capacity❑ Size: Diameter----------------------------- --------Depth--------------------- ------ -------------------- - ------------------------- Privy: Distance from nearest well----------------------------------------------- -Distance from nearest build"sng------.--------------------------------- ❑ Distance to nearest lot line-.--------------------------------------------------------------------- ------- ----- ----------------------------------- 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, State laws, and rules and regulations of the San Joaquin Local Health District. r' - -----�-'----�--------- R �nd�or Contractor) or) (Signed) (Tit{ Y /� -�� e1 (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 ---------------------•--------- DATE- ----------------------------------------- -------- ------------------ DATE------—-----------•----------------------------------- REVIEWED BY ---------- . ----------------------- BUILDING PERMIT ISSUED----------------------------- -------•------------- ------------------ DATE------ V------------------------------------------------- Alterations and/or recommendations----------------------------------- ---------- -------•-- --------------- 1� - V. Date- ------ --��-------------------------------------------- FINAL INSPECTION BY:----------- " -- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 5 camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-24o0 � _._.