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-v APPLICATION FOR SANITATION PERMIT P rmit No, (Complete in Duplicate) __ ___.. = Date Issued . pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the,,work herein describ his application is made in compliance with County Ordinance No 549. JOB ADDRESS AND LO TION:..: _/-_z ------------------------------- _ Owner's Name_.............. L Address------- ---- ----------------- Contractors Name__________ _ _ -_ y i Phone � _� Installation will serve: Residence Apartment House ❑ Commercial Trailer Court , E' ❑ ❑ Motel Other Nu ber of living units: __'-__ Number of bedrooms _ 1' ❑ ' Number of baths __ ____ Lot size ___�__ ___________/1-•--=�_ --�.. Water Su ly: Public system ❑ Community system ❑ Private �th to Water Tableft. Character o soil to a depth of 3 feet: Sand Gravel Sand Loam Fl.,-Clay foam Cla ❑ Y Y ❑ y ❑ Adobe❑ Harder Previous Application Made: Yes ❑ No New Construction: YesNo ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within:200 feet.) Septic T�aIC: Distance from nearest well 63 & Distance fr m foundations-29a______.Materi I ___ ____________ _______ No. of compartments-___ ----------- - Size__s ___-Lic)uid depth------- -_ _Capacity p }Y -- ---- Disposal Field: Distance from near— well Distance from foundation t%1_a_______Distance to nearest to Itne__, [ Number of lines-____ Length of each line____ 'f 5 -- ll Width of trench Type of filter mgterial__. Depth of filter material_•___�-�'____..-_Total length______ _�, ........ Seepage Pit: Distance to nearest well------------------- ---Distance from foundation--------------------Distance to nearest lot line_____ ❑ Number of pits----------------------Lining material---------------------Size: Diameter------- Cesspool: Distance from nearestwell_________________Distance from foundation_.___-____-__ Linin material_: Lining - . ❑ Size: Diameter---- -----------------------------Depth--------------------------------------•--- Liquid Capacity ---- g. Privy: distance from nearest well-________ r_________________Distance from nearest building[] Distance to nearest lot (ine______,. g • 3 Remodeling,and/or repairing,(describe) t:. -- _ � r - - ............... e ..___.... __._______ ________ - . I herebycertify that l have,prepared this a licat�on and that the work*A* be done in accordance with San Joeq ordinances, State laws, and rules end regulations o'F the Sen Joaquin Local Heallth District. - in (Signed) -----4--1k --------------- ---•-- . w +d/o Contrac*.,* By:__. •-- ------- -------- ------- (Tale) Plot lap, showing site of lot, location of system in relation to wells, buildirt s,'e- ( P g g #c., can be placed on reverse°side). _ .r FOR DEPARTMENT USE ONLY APPLICATION'ACCEPTED BY ........... - .............................. ---- DATE........-' ---- _ .REVIEWEQ BY- PERML ------ -- ---•---- - --------------------------------------- RATE--- -------------- BUILDING IT " s. ISSI,tED.._,_� Alterations and/or recommendations:,- _•___: ---•--- -- -- _._ --- - - -- -------- ---------------- ----- -------- --------- ------------ -------------- FINAL INSPECTION BY------ ------- Date SAN JOAQ1J N 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 8-51 Revised W-2100 "