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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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 escribed This applica#ion is made in compliance with County Ordinance . 549. ' JOBADDRESS AND LOCATION rdC't ' " { - -- --------- - ---- -- - - ,- Owner's Name . - ----- --- ----- one Address one-- Contractor's Name____ ----+�- =!�- ----- -- ----G�=d"-- ._.�=1--------- --- _' r h .- ---4� - -----. Installation will serve;„ Residence . Apartment House ❑ Commercial ❑ Trailer -Court ❑, Motel. 0 Other 0 - Number .Number of living units: - ber of bedrooms.`3 Number of baths / ,� Lo# size Water Supply: Public system Community system ❑ Private ❑ Depth,to Water moble ft. Character of soil to a.depth of 3 feet: Sand 4PNo Gravel E] Sandy Loay Loam❑ Clay ❑ Adobe Hardpan ❑' Previous Application Made: Yes E] No ew Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:•. Distance from-nearest well_________________Distance from foundation_______': __.__.Material, No. of compartments____ Size_________ _________ _______Liquid depth __..____ _____._Capacity -__ Disposal Field: Distance from nearest well ____. _____Distance from foundation....................Distance to near-est lot line______ __ Number of lines-. ____ ___Length of each line ______ Width of #ranch ___ Type of filter material--------______----- __Depth of filter material---------------_----3otal length......------------------........ Seepage P, Distance to nears t well/1r! ---Distance,LLfrom�fo dation1A_� ____-.Distance to nearest lot-rne 46 ,, r00 Number of pits--i - Lining material__/f�r_k _Size: Diameter-...?_ ----------Depth----- __ __.------ Cesspool: Distance from nearest well_________________Distance from foundation___----:------.___..Lining-material: ___.__.__ ❑ Size: Diameter Depth= -------- Privy. ----- Uquid Capacity-------------------------•-gals. privy: Distance from nearest well________ ________ _________ _________Distance from nearest building_.______ ______.: __._____- - ❑ Distance,to nearest lot line-------- •-•--- ----- ----- -- •-- -------------- -- ------- --- ----- Remodelin and ar re ainn describe ______________ f ----------- , ---------- --- --•---------- ----- ••----- - ----•-•-- ... -. ............................................. •----- -- - ----- - ------ -•---- --•-- -- -- ---- ---------------•--- ---- ---•-- I hereby certify that I have prepared this application-and that the work will be done in accordanoc San Joaquin County ordinances, State s, pnd rules and ulatio of the S Joaquin Local He District:4 (Signed)------- -- -------------- •--- - -------- ---- ----- --- -----,ee T 40w /or tractor) By:----- - ------..----- .> -, ------- ------- ----------------------------------------------------------(rifle)-- (Ptot:plan, showing,s4e,;of lot, location of system in relation to wells, buildings, efc., can be place on ray-arse We). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By... - --r---- -:--- ---•- DATE...�•� �� - REVIEWEDBY- --------- ----- •- ----- --- ------------------------------------------- DATE --- --- ------- -----=..., ,:---- BUILDING PERMIT ISSUED-->- •--_.-------------------------------------------------------------------------------------- DATE__ Alterations and/or recommendations-- -------- -------------------------------- --=----- ------ -- - ----------------------------------I- - ------------------- •----- ----- ••-------------- - ----_------------ / G ! ' FINAL INSPECTION BY: -- ---• ------ Date - .!o -- c.. } SAN JIOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 8t4 North "C"Street Stockton, California Lodi, California Manteca, California Tracy, California. ES-9-2M 8-51 Revised W-2100 -