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V APPLICATION FOR SANITATION PERMIT Permit No. _ ",? 70 (Complete in Duplicate) Date Issued Applical-ion 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 Ordinance No. 549. JOB ADDRESS AND LOCATION A�' � 1)- -------------------------•----------------------------•-- ----••------- Owner's Name""-"""_.__ __ ----- ------------ PhonA -'r¢- Q�2.3 Address"--------------------- ,2----------)---W4_ 4 - _ Contractor's Name--""""___ -. " " ------ -------•-•--- Ph n -.1a Installation will serve: Residence Apartment House ❑ Commercial E] E]Trailer Court Motel ❑ Other Number of living units: +_'_--- Number of bedrooms _-�Number of baths .1----_ ❑ Lot size __S29 [3•D_________________ Water Supply: Public-system Communifi Y s system ❑ Private E] Depth to Water Table" f}• Character of soil to a depth of 3 feet: - Sand E] Gravel ElSandy Loam E] Clay Loam ❑ Clay [IAdobe Hard an Previous Application Made: Yes El No New Construction: Yes ❑ No p E]TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ; Septic an Distance from nearest well-----------------Distance from foundation---.------ ---------.Material--------------------------------------------- T of compartments--------------------------Size------:..-------------•-- -- • - ------- ---"---------- ----•--- aLiquid depth---------------- ---------Capacity-- = isposal Field: Distance from nearest well-__..-_--------_Distance from foundation-------------- to nearest lot line---.--"-_--- ❑ Number of lines-----------------------------------Length of each line------------------------------ --------_ - Type of filter material-------- .-_---- ------Width of trench----------------" Depfih of filter material-----------------------Total length---------------------------------- Distance to nearest welL__ Ditance fro },�fo�n afion'-_z_Q__," Distance to nearest lot line"�"" _. O LK Number of pits------- ------------Lining material�t_cLF .� ----------.Size: Diameter----.l-_.3----------Depth----- Cesspool: Distance from nearest well-----------------Distance from foundation -- material--------------------------s- Size: Diameter---------------------------------------- bepth--------- ----------•-------- --------------------- Liquid Capacity------------------.- "-.------ - --.gals. Privy: Distance from nearest well"- ------------------------Distance from nearest building---------------_-----_ ❑ Distence`to nearest lot line`: -""_-_"__-"""__"_ _- - ------------------- Op Remodeling and/or repairing (describe)___________ ______ ---------- -- -------- C - -------------------------------------- ------------------ ----------------- --- --•-- -"---- ----- -- ------ •- ----------------------------------- ! hereby certify that l have preparedguthisaons oapplication and that the work will be done in accordance with San Joaquin County a ordinances, State"I and rules and reltif the San Joaquin Local Health District. (Signed)--------- -'t.— ------- --------------------------------{Qhwa,r and/or Contractor 44�7 . -------------------- - ---------------(Title)-- J (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-- REVIEWED BY----------------------•----------- __ __ ----------------------------------------- ------------ --- DATE------ --------------------------------------------- Alterations ---------------- ------ UfLDING PERMIT ISSUED-------------------------------------------------------------------------------------------------------- - ------------------•-"-"=-_ --------------------------------- -------------- DATE----------------•---- A terations and/or recommendations:- - """"""" """ --------------------••------------ ------------------------- -------- -----------------------------------------•-----------------.. --- ----------- FINAL INSPECTION'BY:"" -- ---------- ----------- 1 ------ Date.------ ---------------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street 132 Sycamore Street Stockton, California 814 North "C' Street Lodi, California Manteca, California Tracy, California ES-9-2M ; - Revised W-210o