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z APPLICATION FOR SANITATION PERMIT Permit No. -. -. /-------. (Complete in Duplicate) �\ Date Issued Application is hereby made to the San Joaquin Local Health.District fora permit to construct' nd install the work herein described. This application is made in compliance LI County ordinance No. 549. ,,�+-� JOB ADDRESS AND OCAT ON ..... e.J__. - --- - - ----- Owner's Name ------- ----- - ----- Phone- Address --------------• ............ ---- -- - .. . Contractor's Name 7l�'"`' --•--4 f� '� " - /"�_ .�!rr^ t._.. Phone�' Installation will serve:- Residence Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other ❑ / Number of living units: t,--- Number of bedrooms -4- Number of baths J___ Lot size ___-.-. 'r . !.............. Water Supply: Public E-system inu , ystexs�.❑ ,.Phorate,C[-Depth,to Water Tabl ft. Character of soil to a gepth of 3 feet: Sand ❑ ravel ❑ Sandy Loam ❑ lay Loam ❑, Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATI NAND SPECIFICATIONS: (No septic tank r cesspool permitted if public se is available within 200 feet.) _._ _ Septic Tank: Distance from nearest we Di ante from f¢undation__ �__ Mater' I. _ ` N� of compartmebts-.------ ------ / _--G uid depth Ca acit q p -- p y Disposal Hold: Distance from newest well-Akhois ante from foundation-,Xjl--------Distance to nearest lot ne ...... Number of lines____ er#gth of each lne___:- 4----Width of trench_..,i�,;-_ ------------ f _.. Type of filter material..! Depth of filter materiaL/_r__ ------Total length_____-:-Q__------------------------- [h Seepage Pit: Distance to nearest well_: _____-. ' _.-Distance from foundation ................:Distance to nearest lot line................. _ _ 1771 Number of pits____ _____________Linir(9 material_--_-----------------Size: Diameter--------- --............Depth --•------ ----------------- Cesspool: Distance from nearest well tet'Distance from foundation Lining material--- ------ ❑ Size: Diameter-.--- __,.., _Depth-_----_ ----.--. ----Liquid Capacity. ......... ......•.---gals. l Privy: Distance from nearest well_________ ________ _______-----------------Distance from nearest building_---'_ ---__.__: .................. ❑ Distance to nearest lot line ----'-_ ---• - ------ - ------ -------------- ------------- - -------- Remodeling and/or repairing (describe):_:_____--------------- .......... -- -------------------- )------------------- --------------- ------------------------------- ---• •--------••--------------•--•- -- --. - .` --------------------- _ __.c------------------- I ___ --:•_______I hereby.certify,that I have prepared this application iand that the work will be done in accordance with San Joaquin County ordinances, State I ws and rules and,regulations of the n Joaquin Local H Ith District. } _`." t� �` Own and or ntractor (Signed) - 11 - ( f ) r (Plot plan, showing sh of lot, location of system in relation to wells, buildings,etc., can be placed on reverse,side). - FOR DEPMMENT USE ONLY APPLICATION'ACCEPTED B DATE_ REVIEWED BY- ............. DATE' S,, BUILDING PERMIT ISSUED----- DATE Alterations and/or recommendations- --------- ------ ------------------------------------------------ ------ ------------........................... FINAL INSPECTION BY----- ------------ Date-...----. ) �L -------(-_ -- --------- --------- --------•-------- SAN JOAQUIN LOCAL HEALTH DISTRICT - 130 South American Street 300 West Flak Street 132 Sycamore Street 814 North "C"Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-5,1 Revised W-2100