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APPLICATION FOR SANITATION PERMIT Permit No. _ ------._ (Complete in Duplicate) �J& Date issued . __`'___ _Z3 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 Qr4.inance 4o. 549. JOB ADDRESS D LOCATIO � ------------------------------•--------------------------------------------;�---------- Owner's Name__ __ _.__ Phone - -— ----- 4 �.. � ,. . Address ------------------------------------------ --------------------- Contractor's Name-- =----- ----------- ----- ---------•--•-------------------------- ` --------------- Phone--------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motels❑ Other ❑ Number of livirig units: __I-__ Number of bedrooms -------- Number of baths __f_.__ Lot size ------e_&_-_40-0 •------- Water Supply: Public sysfem Community system ❑ Private ❑ Depth to`Wafer Table'____ ft. Character of soil_to a depth of 3 feet: S;�ONew Gravel ❑ Sandy Lor CaytLoam ❑ Clay E] Adobe ardpan E]Previous Application Made: Yes E] No Construction: Yes Vo ❑i4l. of TYPE OF INSTALLATION AND SPECIFICATIONS: �. s i (No septic tank or cesspool permitted.if public se er is available within 200 feet. 3 z ..., .,�.... ..,. .,,,.......,...s...I Septic ank: Distance from nearest well_-- ista e fro four Afion__-� -----------.Mate 'al-- -- --------------- "r No. of compartmenti . ---_---.__ ize_ __ ----Liquid death Capacity----- -------- [Distance from from foundation___ ___ Distance to nearest lot lin __ __. Dis os a Field: Distance from nearest w il_ ---- - f( P -- --- Number of lines__________ _ ___ ___►_______. Length of each line_________. _ tt Width of trench._- _._ Type or filter mater _ _ __ a__-4-________ °epth of filter material--------- �__.i__Total length__________ __ 1 Number of its_____.____ ( Linin ( ista lce f�founwfi n -- Dist to nearest lot line___ ..-----Seepa Pit: Distance to nearest we I________ Q, ---- �" �j p' ------- g Diameter L ------Depth--- ---�V.0 l' Cesspool: Distance from nearest well-!............ _Distance from foundation--------------.---- Lining material--------------------____.------------ El __ .-______Size: Diameter--------------------- JDepth ,---------------------------------- --------Liquid Capacity- --------------------------gals:_ Privy: Distance from nearest well- __ ._'_______ ____.___________Distance from nearest building--------- ---------- --. ❑ Distance to nearest lot line_ --_--_�--- - --'_ -------------------------------------------- ---------------- R m eling nd or r airing { scribe)_____________________ _____. ____- -- - --- ---------------------------- - ------ ! 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 Contractor) ;;7- 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 _________________ DATE-? ------ ' ---------------------- -----------------------•--------------------------- �� --------- REVIEWFDBY------------------------------ ------ ---- --------------------------------------------------------------------------- DATE__---------------------------------------------- BUILDINGPERMIT ISSUED--------------- --------------------------------------------------------------------- --- --.._ DATE---------4�--------------------------------------------- Alterationsand/or recommendations:---------------------------- -----------------------------------------------------------------------------•-•-------••---------•----------------------------- ----------------•-•------------- -------------------------------I---------------------------------------------I-----------. ---------------------------------------------------------------------------------•------------ ----------------r------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------•-•----•-------------- --------------------•----------------------------------•------ � � FINAL INSPECTION BY:........./I--- 1� '�° -------------- Date ----------- --------------------- 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 I ES-9-2M 10-52 Revised W-2100