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APPLICATION FOR SANITATION PERMIT Permit No.13._Q0 (Complete in Duplicate) Date Issued 4/1. 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 Ordinanc No. 549. JOB ADDRESS AND LO ATION--------- -----------._ 0.., �� Owner's Name------- •---------------------- --- -- ----------•------------------- - --- _•,___-. _ --,-•- - ---- - --- ---- -------- - ------ Phone._ Address - ------------------- Contractor's Name------ -- __-- ---- Phone-- Installation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ ❑ Motel ❑ Other ❑ Number of living units: _/___ Number of bedrooms_ Number of baths Z___ Lot size Water Supply: Public system Communitysystem y ❑ Private ❑ Depth fie Water Table�Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe.' Hardpan ❑ r Previous Application Made: Yes ❑ NOX New Construction: Ye�< No I] 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 Is ar p ,s ante from foundation__ _ Material- _- - ---------------------- No. of compartments-_,_. Sixe -' __Liquid depth -------- ----Capacity_.. ------ Disposal Field: Distance from nearest wel,�� _ ,`stance from foundation ------------ ----------------- Distance of of trench------�---------------------- Type of filter materia1-1-2—_ -----Depth of filter material___ __qq_ Total length___._ Q --------_ Seepa e Pit: Distance to nearest well_ rsfance fr foueation-_ . -_____.D,stan� to nearest lotdumber of pits. ----------Lining materi /� Size: Diameter_ -- -- - .....Dept h------- -) / ------------------- Cesspool: Distance from nearest well________________ Distance from foundation ❑ , Diameter.- D ---------Lining material------------------------------ __.-___ -____..--____--- ----gals.Privy: Distancefrom nearest well----- ---------- p ----------------------------------- ----------------Liquid Capacity------------•---------_----- -- O dt ________________________ ________________Distance from nearest building--------------------------------- _ ❑ Distance to nearest lot line___________________- Remodeling-and/or repairing (describe)-------------- ---•----------------------------------•-------•- ------------------ -----------------------------------------•-•------..------------•---------•-------------------------•------------------------------••--------------------------------------------------------------------- I hereby certify that I have prepared this application and that th work will be done in accordance with San Joaquin County ordinances, to laws an rules lotions the S Joaqui ocaE Health Dis riot. (Signed).._ __ cry c-__ _Owner and/or Contractor) y — / By�------------ ----- -------•------ (Title - " y 9 -- -----------slide). - ----- (Plot plan, showin size of to , location of system in relation to wells buildings, etc., can be pl d on reverse FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_.__ DATE"_---____ ------ ----------- ---------------------------------------------------------------------- REVIEWED BY----------------------------------- ------ - -------------------------------------------------------------------------------- DATE------ ---------- BUILDING PERMIT ISSUED------------------- --------------------- DATE_.--------00-------------------------•---------•--- Alterations and/or recomme dations__________________.__--_____:._ _.___ __ --------------------- ----- a�, ------- - .- --- -ca- ---------------------------- ---- ---- ------- -------------------------- ---------------- --------- --- -------------------------------- - = L5 FINAL INSPECTION BY--------------------- ------ Date--------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California »�} Lodi, California Manteca, California Tracy, California f� ES--9-2M 10-52 Revised W-2100