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APPLICATION FOR SANITATION PERMIT Permit No, r (Complete in Duplicate) Date Issued Application is hereby ade 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 L CATI N-------------- -------------- ---------- - -- --- - - ----------•-------•------------ Owner's Name---------------- _ ----------- - 21� ---------------- ------- ! Address. ---- ----J-- -- -- ----- - _. _ __ _ -_____.. 4- Contractor's Name----- �____ __ ____.. -- -- --------'!� --- - -------------- Installation - --------- Phone Installation will serve.t' Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 15 la------------------ umber of bedrooms ____/__ Number of baths I--- Lot size Number of living units: . �-- � Water Su I Public system Community system El Private ❑ Depth to Water Table 14 1 PP Y Character of soil to a depth of 3 fee+; Sand Gravel ❑ Sandy LoVN, lay Loam El Clay El Adobe Hardpan ❑ Previous Application Made: Yes ❑ Na New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if.public•sew r is available within 260 feet.] 0------- material_ -roll Septic T Distance from nearest weil_M_>V✓-. _Dis+ante from #oundation_1 No. of compartments---2------------------Sxe �} ---Liquid depth--- -��.-------- Capacity----�4�d---- - f L- - .Disfiance to nearest lot line__v5_ _ ___________ i Disposal d: Distance from nearest well ._ _ --_ Distance from foundation_ ___.__._ f Length of each line__--- Width of trench---_.-._ h Number o'1 lines_--�k�- - -- -- ,g ��-----ice---� --� --•--- Total length------- .. -��-'f'`'. Type of filter material_=__ Depth of filter mater al____ ___ ____________ I - - f ______ ---------Distance from foundation--------------------Distance to nearest lot line-------------- . Seepage Pit: Distance to nearest well_- _ Lining material ----------------Size: Diameter------------- ----__Depth--------- ---------------------- i , E p f�umber o pits------------- Distance from foundation.----------------_--Lining material------_------------------------------ nce om Cess❑ool: SDizcaD'amieter-neatest well - Depth ----------------------- -------------------- Liquid Capacity- ---gals. � Distance from nearest well---------------------------------------------- -Distance from nearest building--_---_---------------------------------- Privy: ------ ❑ --------------------- ----- Distance to nearest lot ine-______ _____________ - - 4e Remodeling and/or repairing Idescribe):------------- --------------------- _ _ ----------------------------------------------------------- .�----- --• - --------------------------------------- ----------------------------- 3 bt.AkA s t. ------------ ------------------------------------------------c, -------------- ------------------------------ - ----- -- ---------•------------------------------------•---------•----------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. r r � ��_,,/ � � p / r Contractor -- -/----6_t_ -" :�"��" caner �d o (Signed) `" c (Title)----�" -7—-------------------- --------- - ._. &&---------- - Y' (Plot plan, showing size of lot, location of system in relation to wells, buildings, a+c., can be placed on reverse side}. t FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED By - _ ___ ------ DATE_ p--------------------------------- REVIEWED BY--------------- --- .�1 -------- ----- --------- ------------- -------------------------- DATE--- _------------------------------------- ----------- BUILDING PERMIT ISSUED--------------•------------------------- ----------------------- ------ DATE--------- ---------------------------------------- Alterations and/or recommendations-------------------------------------------------- ----;-------•--------------•--------------------------------------------------------------- --------•----------------------------------- # ---------------------------------------------- E - -'--------------------- --------- ----------- ----- FINAL 'INSPECTION BY:--------- --- ---- •---------------- Date------- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North '"C" Street 130 South American Street Tree California Stockton, California Lodi, California Manteca, California y. ES-9-2M 10-52 Revised W-2100