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APPLICATION FOR SANITATION PERMIT Permit Nor�Z.1.-/-4-_-- ��*� (Complete in Duplicate) Date Issued��.�l�.S'� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work here This application is made in compliance with County Ordinance No. 549. in descried. JOB ADDRESS ANDPO ATI Owner's Name ----------------- -------------------- ------ .: _' - ---------•- Address--------------------`- •�--� � .� Pone. - - ------------------ - -------------------------------- Contractor's Name... ------ - ------ - Phone.- Installation will serve: Residence Zj,A<partment House ❑ Commercial ❑ Trailer Court ❑ Motels❑ Other ❑ Number of living units: __-/-. Number of bedrooms -- �.- Number of baths .-_� Lot size ---- Water Supply: Public system - y Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe jL,-4'ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes Eq--?To ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic -1a Distance from nearest well - Distance from foundation-_ �( No. of compartments__----- ��-- �-�------- Mat nal___��. ..7�1 --- ----Size--.ate ----L+quid depth_+ _ p Capauty {} Disposal Id: Distance from nearest well -ILQY—Distance from foundation---a. -___ . Qistance to nearest lot line-,,S710 Number of lines-.__--� Length of each line - gaT - --- Width of trench- Z_ . �- - � --- -- �- - Type of filter material_ -Depth of filter material__f._F---�-X------Total len th ____ __ Seepage it: Distance to nearest well.,_°Vr -%_ _Distant frpm undation_--_ s Cr Q-----_.Distance to nearest lot --0-_.- Number of its.. ll - ! �..... . _Size: DiameterDepth_ p I- -- .__-.-_Lining materia �' Cesspool: Distance from nearest well____________ __Distance from foundaf•ion.-_ _ --------------Lining material.... _ `:_--:: -❑ Size: Diameter--- -- --- - ------ Depth.................. Liquid capacity --- ............... ----- -.gals. --------- Privy: 'Distance from nearest well--------------------_---- Discan�e from nearest building El Distance to nearest lot line ---.----- ---- g - ----- ----------- ------ --- -- 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, (Signed)---------- - -- - -------(Owner and/or ontractor) --- (Plat plan, showing size of lot, location of systt m i -n relation to wells, buildings, et - Title---c reverse side).----------------- g , c., can be placed an reverse sde). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY'--,- REVIEWED Y`,; ----------------------- -- DATE- ------ REVIEWED BY-------------- --- --- - ------`�=�----€ ._ .--- - - - -- - ---------------- BUiLDING PERMIT ISSUED------ --------------------------- ==-------.- _ ---------- ------ ----- A terations and/or recommendations:................_ ------ DATE- ------------------- --------- ---------------- ------------------------------- ---------------------- ------__----'-.----------.----------------------- FINAL INSPECTION BY:. ---- - ---- ------------- ... . " -- Date.. - - ---'.l. --t€ f - ----- .1 -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street F32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100