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APPLICATION FOR SANITATION PERMIT Permit No.d_jJ2_ -JI a-l4 V (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct a d install the work herein described. This application is made in compliance with County Ordinance No. 549. )JOB ADDRESS AND L ATIO _ --------------- ----------- Owner's Name------------- --- - ---------- -- -----='-'- ----------- - - ---------------------------------------------------- Phone------------------------------------ Address-.--.------------------ -----------------------------------Address-•--------------------- ------------------- Contractor's Name----- -- ---- --4-- --------------- lir �+•��.�(,f Phone----,4.-'- Installation hone-- -Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __-_ N er of bedrooms I Number of baths /---- Lot sizeI- rQ__{ __ -- ---------- -----Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tablft. k Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Lo;eo ay Loam E] Clay E] Adobe Hardpan E]Previous Application Made: Yes El No New Construction: Yes TYPEOF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if blic sewer is available within 200 feet.) It £ Septic T Distance from nearest well 7-'�_Distance from foundation-!__________.Ma . rial__ ___ _____________________ ❑ No. of compartments--w -------------------Size__.,, - ,�'�___-------Liquid depth_, __We--------- ----------- '� Disposal R d: Distance from nearest well O---------Distance from foundation___)__A__ Distance to nearest lot line---hP-------- ElNumber of lines_____________-- __ Length of each line____ ----40_ __ _ Width of trench r T e of filter material_ �_ e fh of filter material___ Total length______ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line_______________ VR ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------- Cesspool: Distance from nearest well______-_-_Y_____Distance from foundation------------------- Lining material-------------------------------------- CA ElSize: Diameter-------------------------------------Depth-----`-----------------------_=--------------------Liquid Capacity-----------------------------gals. i Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------.--______________- Distance to nearest lot line-----------------.------------_ Remodeling and/or repairing (describe)--- -------- ----- ---- ---------- � �--- ---- •--=-----�•---------•-------------- V, -------------- ------- ------------------------- _---- -- = — ----------------------------------------------------------------------------•------------------------- --------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that +he work will be done in accordance with San Joaquin County a ordinances, State la and ales and regul 'ons of �e San Joaqu' Local Health Distri 1 � r Own mead ar C r''itractor ------------ - --� --------- -- --------- ------ (Signed: l [ �. I a► gY:--_------- — A [Tit e) --- ----- (Plot plan, showing size of lot, Ioca+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___________________ DATE----------- _ REVIEWEDBY----------------------------------- ---- -------------------------------------------------------------------------•--- DATE- --------------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------- ------ DATE----------------------- -- --- Alterations and/or recommendations:_ "-' ' SCJ` �' ----- - ------------------------ -------------------------------------------•------------------------------------------------- =ay, --------- -- -------� .� '�'� ,----------------- ----------- --- "` ---------------------------------------------------------------- ---- ----------------------- FINAL INSPECTION BY:----------�._ -- -------------------------------- Date , 1 °j� x SAN JOAQUIN LOCAL HEALTH DISTRICT T130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 ES-9-2M 8-51 Revised W-2100 0.