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APPLICATION FOR SANITATION PERMIT Permit No. <br /> (Complete in Duplicate) �1.. / 6 <br /> Date Issued ......... <br /> Applica�ion is lsereby made to the San Joaquin Local Health District fora-permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. ., <br /> JOB ADDRESS AND LOCATION-144.............. - - ----- __L.'�`-7 t. a' I`B'C.G xe <br /> s�� <br /> Owners Nam - -._...- Phone-•••- r „ � <br /> s <br /> Address--... _ ...--�-•-- ............... .. ..... •_. ,.. ..... .... --- •••• -- .._--- <br /> Contractor's Name... _ ---. -"... - ­- •-•--• ............ Phone_ ......-•-...................... <br /> Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court❑ Motel ❑ Other 0 <br /> Number of living units: _jtT'--- Number of bedrooms '--- Number of baths _j... Lot size ..... "rY_ - -_-----_-------------- <br /> Water <br /> -.__ -_-•_ -____-- <br /> Water Supply: Public system ❑ Community system ( Private❑ ` Depth to Water Table ........ ft. <br /> Character of soil to a,depth,of 3 feet: Sand ❑ GravallD. . 11oalo: (' :Clot.Loa o. .Clay.❑ Adobe Hardpan <br /> Previous Application Made: Yes No ❑ New Construction: Yes ❑ No ❑ <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well...................Distance from foundation..........._,..__.Material_ . ...___._ .•._,._ „-_.-,__ --_-__--. <br /> ❑ No. of compartments._--_ Size............................. ____Liquid dept -------- -Capacity.,— to <br /> Dis I Field: Distance from nearest well distance from foundation ��, Distance to nearest lot line <br /> ' Number of lines-­-------­---------- Length of each line..........Z_--.. Width of trench .Z- .............. <br /> Type of filter material.... ___ Depth_of filter'material.......1-8"*____Total length........./.w.Q .r.................. <br /> Seepage Pit: Distance` to nearest well_ _____--- _-- _..Distance from foundation....................Distance tonearest lot line----------------- <br /> ❑ Number of pits......................Lining material-.-__ .---_-------.Size: Diameter.-_._. ............ <br /> ...:=.Depth--------------------........... <br /> Cesspool: Distance from nearest well.................Distance from foundation_.- ..__.........Lining material.. . ..-,..;. __.._'.....___.._... <br /> ❑ Size: Diameter---- --------- -------------------Depth......................................................Liquid Capacity ................-------gals. <br /> Privy: Distance from nearest well_____________________ _.._ __._.-.____Distance from nearest building---------------------------------------- <br /> Distance to nearest lot Fine------- -•-••• ----- ----- ------ -- ----- - -1 -... <br /> r re airin describe <br /> ............................................................._ -----•• ---•--. ------ ---•----- -•-•--- -•••-• ------• •--•--. -••-•--• --•-• ---•--. ------. -•---•--- <br /> I hereby certify that I have preparedA"on and that the work will be done to accordance with San Joaquin County <br /> ordinances, State laws and rules and regSen Joaquin Local,Health pct. <br /> (Signed) .....�,�„�t ti ----- ------ -----n--r-JOWtle1 �+ef/or Contractor) <br /> ----- ------- --------(rifle)-- ------ .--:.--• ------. ---- -----(Plot plan, showing size of lot, location ofio to wells, buildings, etc., can be placed on reverse side).: <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.... . . •. -..._..I-- ••------------• DATE..................................................... <br /> REVIEWEDBY., --- •--•-----------•--------------------------•---------------- -. .... - •. -----. ......_.. DATE ----•-• •---•- --------- ------ <br /> BUILDINGPERMIT ISSUED...................................................................................................... DATE..................... __............... <br /> Alterations and/or recommendations:--- ----- --•-- `------. ....I............�:,. _. ............................................................................ <br /> FINAL INSPECTION Date...._ / ........................ � > <br /> ••----•........ <br /> SAN JOAQUIN LOCAL HEALTH 'DISTRICT " � <br /> 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North'°C" Street <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M Revised W-2100 <br />