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N / �l9 5APPLICATION FOR SANITATION PERMIT Permit No. "'S~� (Complete in Duplicate) p 4ZI 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 Or inance No. 549. JOB ADDRESS ANDLOCATION ` /� :_.._._.. `-' ''�-' --------------------------------- = / Owner's Name....... ------- - --•------------------------------------ ------- ----- ------------------------- Phone--,,57: -- --------- Address-••-----•---••• = ------. -- p� ! Contractor's Name------•-•--....... ----- -- -------------------------------------------------------------- Phone/--•--/..O'------ •. Installation will serve: Residence [►Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -; Zmunity .._ ber of bedrooms 3_. Number of baths _�_.... Lot size_ .d__ __� �{'_______________________ Water Supply: Public system system ❑ Private ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe D"Hardpan Previous Application Made: Yes ❑ No New Construction: Yes [Er'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public;ewer is available within 200 feet.) Septic nk: Distance from nearest well------h-----Distance from foundation------ZO--------Material_0----- Zvv/� _______ No. of compartments---_. .•2._.__-----Size--------------------------------Liquid depth---------------------------Capacity---f---W Dispose Field: Distance from nearest wgll___.!0_Q.____.Distance from foundation.1X90 .....Distance to nearest �ot�fe_..�-f�__._...� Er Number ort lines____.__._._./___ _______ _____ Length of each line . .__._.__.Width of trench.___.____,____ �} . y„ � o ,---------.----------- Type of filter matenal_` _____ __Depth of filter material-----I_ ---- Total length_________ ____---------------------- Is __ __________________ See a lt: Distance to nearest well_... ! . _Distance fr fo n ation...... .__ 4 p g 7 Q..__..Distanc��to nearest lot line_;.- Number of pits--------- -----------Lining material---�-D-_C,_- Size: Diameter.....��----- .Depth-----a--------------------------- Cesspool: ', Distance from nearest well_________________Distance from foundation.-------------------Lining material-_:_-----_--_._-_______---.___-____-.. ❑ Size: Diameter---------- ---------------------------Depth-------------------------------------------------Liquid Capacity---•--•--------------------gals. Privy: Distance from nearest well_______ _ ___ ___--____-.......................Distance from nearest building------------------------------------------- Distance _--_-.-___-._-__ --._:---- _-_._-.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 ire ulations of the San Joaquin Local Health District. (Signed)•--_----41_.. : . ----- -- ' (E w*"r and/or Contractor) By--------------- .a° {rile) --- (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----------- ". � REVIEWEDBY-------------------------------------------------------------------------------- -------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED....................................................................................................... DATE------------------------------------- ----- Alterations and/or recommendations:--------- ---- -------------------------------------------------------------------------------•---------- ------------------------ ----------------------------------------------------------------------------------------------------- ------- -------------------------------------------------------------------------------••-----------•-----.........----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------•---•- ---------------------------------- --------------------•-----------------------------------------------------------------------------------------------------------------------------•--------------------------------- ---------------------------------- ------ ---- --------- - ----- ---------•--------------- --------- ----------------.. . FINAL INSPECTION BY... ----------------------------------- Date.... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" $treat Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-V00