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Perrriit No . ._.... APPLICATION FOR .SANITATION PERMIT (Complete in Duplicate) / Date lssued��'�,1' T 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 Ordinance No09 . 549. JOB ADDRESS AND LOC ON...: .�6 --••--- = = �._ "-- . : _. --- - ........................... - .: f� -- Phone------------------------------------ ------------------------- ---•--- ------- --------- Owner's Name---•--------- �---- - --- --------- - - ------------------------ Phone _:.. 9 . . ----•• =--- ---- Contractor's Name------------------- ------------------- ------------------ ----------•-----------------------------••---- Phoneme; -------- -----.->..•.-•-•- Installation will serve: Residence F] Apartment House 0 Commercial ❑ Trailer Court 171 Motel, Other 18f Number of living units: ._ '..'Number of bedrooms :El_. Number of baths .'Y. Lot size ..t)....- -•-:mgq ...._i_.......... Water Supply: Public system ❑ Community system '❑ Private ® Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [M Clay Loam ❑ Clay❑ Adobe[❑ Hardpan❑ Previous Application Made: Yes ❑ No J New Construction: Yes R1 No Fj TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well__l__20.0 Distance from fgund ton....l!�_--___-..Mafe�rial._Cho �-r, .e., No. of compartments __-_%�---------------Size A!!........X ._ '_,___Liquid depth-------5- __.-.__Capacity _.' Disposal Field: Distance from nearest well /7 � Distance from foundoet istance to nearest lot line � js. - `r Number of lines.--------- --Length of each line, ;1 Width of trench.-- _-_-_156. -- ®` g - I- -------Total length..Type of filter material___$rild-____Depth of filter material /�'__ g yi Seepage Pit: Distance to nearest well_ _-______________Distance from foundation ......._____._Distance to nearesf ghne_.__........___• ❑ Number of pits-----------___-----Lining material-----------------------Size: Diameter____---___-__________.Depth---------------------........... Cesspool: Distance from nearest well_________________Distance from foundation____ _._____...__.Lining material__.----------------------------------- Size: _--________--__-______ :----_•-:Size: Diameter------------------ ----------------Depth---------------- ----- --- -----Liquid Capacity ------------------------gals. Privy: Distance from nearest well----------------- -- --_- Distance from dearest building___-:: . ..........-.- Distance to nearest lot line------- -------- - ---- -- ----- --- --- - -- ---- ----- -- ----•-- -----_. ....... ----------- Remodeling ------- -Remodeling and/or repairing (describe):______ _____ ------------- ------------------------------------------------------------------ ----------------------------------------- -- --- --- - ---- ------- ----------------- ----- ------ ---------------------- --- ----- --• - - - --- ------ _ I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County r ordinances, Statp laws, and rules and regulations of the San Joaquin Local Health District. (Signed)........ . .... .'ti'''}"��' �''�`"--- ---_--_---------(Owner and/or Contractor) BY .---- ------•- ----- --- ----- --- ------------------------------------------------ -- ----------------(Title)----------------------------------------- --- ---- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse sidej. FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___ __. __�-__ __-,.___. -- -, .-=-- , .-- ------------------ --------- DATE--- -- ---*?'=-.�- --�--r�'---------------------- REVIEWED -- ------ ----•---- REVIEWED BY DAM_----- -• ,.., _ BUILDING PERMIT-ISSIJI~D--- __.----- -- - ------ - ..� - AT - - _. c� r .._ •-- r�o - - - . -- ----- --- - - --_- ------- - FINAL INSPECTION BY:..------- Date - ----- --------- =------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak•Streat. 132.Sycamore Street- 814 North "C" Street Stockton, California Lodi-, California Manteca, Cal[iforrRa Tracy,,California: ES-9-2M 8-51 Revised W-2100 '> _r;