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APPLICATION FOR SANITATION PERMIT Permit No. `fi \� (Complete in Duplicate) �z Date Issued Application is hereby made to the an 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............ -------- Owner's Owner's Name..__. a __-_- N-sL_ .y ----- ------------------ ---------------------------------------------- Phone Address----------------- ---•--- ----- ----- ----- Phone. Contractor's Name Installation will serve: Residence (�partment House ❑?? Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .!_._.__ N mber of bedrooms -3--- Number of baths I----- Lot sizeo_.�•_••_______________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. ` Character of soil to a depth of 3 feet: Sand ❑ ravel E] Sandy Loam Clay Loam D Clay E] � Adobe• I1aardpan ❑ Previous Application Made: Yes E] No New Construction: Yes No [ IA/VA: Yes ❑ No [Y'' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tan . Distance from nearest well_________________Distance from foundation--------------------Material _.__.____-_______-__________.___.___.-__--____... ❑ No. of compartments--------------- ------Size--------------------------------Liquid depth----------------------- -Capacity ----------------------- Disposa Field Distance from nearest well-_J&~-- -- from foundation _____.__. Distance to nearest lot line__..S______ Number of lines___ _______________ _ Length of each line__-___._S___4�____--_.Width of french----2-'Y_'/ ---------------- Type of filter material__ _ _ _______.Depth of filter material__ __ _:/�__ --- length r 9 --•-------- Distance to nearest ell---AV4'`�f--__Distance om f undation__./_ r� /a.__..___._i nce t�nearest lot line ____-__� (A Number of pits____ __--__________Lining material---/K ----Size.:a IsFer °• *--?-_Depth___,.-;MMW _-__ I Cesspool: Distance from nearest well___ ___________Distance from foundation--------------------Lining material___-___-_____________-_______-______-. ❑ Size: Diameter------------------------- ------Depth--------------------------------------------------Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest buildin ❑ Distance to nearest lot line - - 9 Remodeling and/or repairing (describe):----------------------------------------------------------------------------------------- ---------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------- I 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. d ( Si ne�9 ) --- '_ ` .tet- - ` ---- -- ------------------ ------- - -- l (Owner and/or Contractor) By:---------------- - -- - ----,7 ---------------------------------------------(Title)----------------------------------- -- ------------------------ - (Plot plan, showing size of lot;�location of system in relation to wells, buildings, etc., can be placed on reverse side). JFORPARTMENT USE ONLY APPLICATION ACCEPTED BY-------... DATE ------------------- EVIEWED BY --------------•------- --- DATE------ ----•------•---------------------------------------- AIteDING PERMIT ISSUED-------------------------- DATE -------_. ..__.___. rations and/or recommendations:________. ----------------- --------------- - - q7-------------- ------ ------ `- 1 ' T-- ------- ----- FINAL INSPECTION BY:---- - _ ✓ - --•----�----------• Date.----- -----=�--=------------------------ SAN JOAQUIN LOCAL ALTH 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 , Revisea 1.57 F.P.CO.