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Permit No. APPLICATION FOR SANITATION PERMIT I J x (Complete in Duplicate) Date Issuedf'2, - v 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 No. 549. _ -r----_�------- 0- -�---�------ - •--- JOB ADDRESS AND L CATIO ---•------ _ ---- ------------------------•--------- --------------- --- ------------------ Phone Owner's Name----•---------- �-rze -•--i - l ,_.r ----------------------------•---------------------------••------------_:.-•-------- Address------ ----------------------------------------------------=-------------------- Contractor's Name--------------------------- �- �--�--------- --------------------- ---------- --------- ----------- ---------------- Phone-------------------- Installation will serve: Residence A HCommercial E] Trailer Court Motel ❑ Other ❑ iApartment House ❑p ❑ -t-ry---/�--��_�_.------ J v C Number of living units: .___'- Number of bedrooms -.2— Number of baths --- --- Lot size __n__- - (� Water Supply: Public system El Community system '❑ Private# Depth to Water Table J�ft. Gravel Sand LoZ�No Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Character of soil to a depth of 3 feet: Sand�] ❑ Y Previous Application. Made: Yes ❑ No ,L_,f/ New Construction: Yes ❑ 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----------------- from ❑ foundation--_________---__._.M_ aterial_ .____-_____-____._-_ _______-____-____._---- - Size---------------------------- --Ls Liquid depth_________________-___----Capacity---------------------- No. of compartments-------------------------- rest lot line____.____._.___. Disposal Field: Distance from nearest well-----------------Distance from foundation_-----_- Distance to nea ❑ Number of lines-----------------------------------Length of each liner-=-------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of fifer material-----------------------Total length-------------------------------------•---- Seepage Pit: Distance #o nearest well_____________________Distance from foundation--------------------Distance to nearest lot line-------- -Linin material-----------------------Size: Diameter Depth = ❑ Number of pits---------------------- g E Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material___ __________--__-_________.____. --De th :------------------------------- Liquid Capacity::----------------;-�--•--gals .,�- ❑^-"-� ^ .Size: Diameter_ :--_r : _ i Privy: Distance from nearest well----------- d---------- ---------- --Distance from nearest building -b-- --------------- Distance to nearest lot lire_----------------------------_ + Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------- - ----------------------------------•------•----------------------------------------------------------------------------•---------------------------------------- ----------- ___________________________________________________________________________________•-__.____..._________ -----------------------------------------------------I------------------------ _ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Dun ty ordinances, State laws, and rules and-regulations of the San Joaquin Local Health District. • � v ------ -------------.---------------------(Owner and/or Contractor) (Signed) rte}I ----- - - ------------------------------- -- -- ---------------------------( (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---------------W ----------------------- DATE --------- - REVIEWEDBY------------------------------------------------------------- ----------------------------------------------- ------------- DATE _ BUILDING PERMIT ISSUED---------------------------------------------------------------------- DATE------------------------ = Alterations and/or recomme dations--------------- ---------------------- -------- --------------------------------------------------------- ; _ I Le-1----V-64- ------tT---�o--tny`�" , 1 Date_.W -- FINAL INSPECTION BY.,," - ` SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y A ES-9-2M 8-51 Revised W-2100 `= .2 ':f