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APPLICATION FOR SANITATION PERMIT Permit No. _. .-.. (Complete in Duplicate) Date Issued ....* 53r... Applica+ion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION._(/ Owner's Name-- ,".,►�- ----------- ---------------_----- -------------- Phone.................................... Address-----S)-�.........- ---- - - Contractor's Name � _.._ ................. P h o n --IT.L Installation will serve: Residence ..Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ./____ Number of bedrooms 2_ Number of baths /..... Lot size __ a__. ___f_ d^------------------ Water _ _--__-- -- Water Supply: Public system. &r_ftmmunity system ❑ Private ❑ Depth to Water Table + ,.7t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan E] Previous Application Made: Yes ❑ No 4—.New Construction: Yes 9—Uo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank;or cesspool permitted if public sewer is availabfe within 200 feet.) � no Septic Tank: Distance from nearest well)%o.%_t.—_Distance from foundation-._/a_.__-/.44 ^A C- ,-- +_ No. of compartments_______, —----------Size... _..Liquid depth..4L s ______ Capacity Disposal Field: Distance from nearest well_ Distance from foundation-.AL. '....._.Distance to nearest lot line...Afl.t.... Number of lines- __.___ _.___. . Length of each .�_Q______________Width of trench...,Z„y_/-' _.---------------- Type .__._______.___ T e of filter material��_L ___ .De th of r. ie+' �� -__Total len th......._ ID-,'_•-••_________________ YP �� p � - -�------- g �- i Seepa a Pit: Distance to nearest well ' -^ Dist ce om fou dation_._ __.....Distance to nearest lot line...//_._.__. Number of pits__.-------- --_ Lining mate ial_A .Size: Di meter.{_________ ____Depth__.1_0._.....__....._.___. Cesspool: Distance from nearest well.................Distan a ion ___________,____.Lining material--------------------------.......... ❑ Size: Diameter--------------------------- ----------Depth----------------•--------------------------------- Liquid Capacity--•-----•-----------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building._-.__.-___•.__-___-_________________-__. `'11 ❑ Distance to nearest lot line------ ---------------------------------------------------••---•---------------------------•-----------------.----------------- ---- Remodelingand/or repairing (describe):-------------------------.......................................................................---------•-----•--•----•----•-•------••-.............. ----------•----------------•-------------------•-----------------------------------------••-•--•---•----------------•-------------••----------•--•-----•-----_•----•---•----------•------------•----------------------------- - -------------------- ------------------------------------------------------------------------------------------------------•------------------------------------------------------------------------- I hereby certify the+ I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St to laws, and rules and regulations of the San Joaquin Local Health District. ( Signed' r Contractor) By:------ fglk -------------------•----------------------------------(Title)------------ --- ------------------ (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__ __________ __ _ __ lip _ DATE._.. _..__...__ . . REVIEWED BY ��-- �------------------------ DATE-- '"_.. .......: ------- BUILDINGPERMIT ISSUED.................................................................................... ----------------- DATE............................................................ Alterationsand/or recommendations----------------------------------------- ------•..'_._....•-------------------------------•---•-----------.....------•-----•--•--------....-••--.....--------- ---------------------------------------•------------•------------------------------------------------------------------------------------------.............---....------------------•---••-------•-•--............---•----•- ----------------------------------------------------------•---•----------------••••---•---••--••-•-•••--•-------•-----•---------------••-•--•-•--•••---•---••--•-•---•-•---•-•---••--•••...---•------------------•-•------•-- •---------------------•-------•--.......--•---•--------•---•-....-•-----------•--....._..--•--••--•---•---------------••-•-••-•-•--•------------•--------•--•••----•---------......---•-•-••-------••--•--•-•---------••-•--.. ---------------- ----------------------------------------------------•-------•------•------------------------ ----------------------------------------•----------------------------•--- .................................... FINAL INSPECTION l BY:----_�.�--_� � �-------- - ---------------- - Date_..._-.: :-------- ---------------------J---- --------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M � vise 2100-