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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ---- Applica+ion 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: ,t,2S. '6 , 0_0'? J013 ADDRESS AND LOCATfON__6,^_.t____/_V,9______ 4-e �� !Y-___--- _-�!•. Owner's Name__ . ��4 --------- ------ Phone----------------- Address ----- ---------- ddress ---------- •--------------- Contractor's Name -------------------------- Phonely ' .L�1 - --------------------- Installation will serve: Residence E]'�_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ --- Number of bedrooms -_— ._ Number of baths ___l__ Lot size ------;7- __/�_I.4`,'�_----------_----------- Water Supply: Public system ❑ Community system ❑ Private ®. Depth to Water Table)-` ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay p AclobeE!�, Hardpan ❑ Previous Application Made: Yes ❑ No m New Construction: Yes [] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta, :, istance from nearest well-----------------Distance from foundation--------------------Material_______ ---------- ❑ of compartments------------- ------------Size-------------------------------Liquid depth-------------------------- Disposal ------------- ----------Disposal Field: Distance from nearest well----�'�-_Distance from foundation___-`�---------Distance to nearest lot line_____��___~_._. Number of lines------.-----_ -- .........Length of each line--------Lai . __`-�--.Width of trench _ - Type of filter material___1.3___..5fDepth of filter materral___.__I_ _______._Total length____.--_ _ Seepage Pit: Distance to nearest well------------------- ---Distance from foundation------_-------------Distance to nearest lot line----------------- A ❑ Number of pits______________________Lining material----------------------- Diameter----------------- __.Depth-- -------------------------- Ir Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__.. ___-___________. 7, ❑ Size: Diameter----------------- --------------------Depth----------------------•----------- - - 2. - - - ------�Liquid Capacity-- ------- -----------------gals. Privy: Distance from nearest well____-_.__.__.---_------------------------------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 the work will be done in accordance with San Joaquin County ordinances, State ws, and rules and regulations of the San Joaquin Local Health District. (Signed),.,------- ----.[ ._ � -------------------------- -----------•-------------- By. / � � (Owner and/or Contractor) ---------- --------- ------(T�tlel - cis _ .___ (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 APPLICATIONACCEPTED BY------------------ -- ---- ----------------------------------------------------------------- DATE------------•-------•-------------- IEWEDBY------------------------------------- ---- -- - - --- BUILDING PERMIT ISSUED • ---- --- - ---------------------------------------- DATE-----------DATE Alterations and/or recommendations:_______ _______ ------------------------ FINAL INSPECTION BY:.. 't� 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 ES-9-2M ; Revised W-2100