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APPLICATION -FOR SANITATION PERMIT (Complete in Duplicate) Permit No. Application is hereby made to the San Joaquin Local Health Districfi f Date Issued _�// •_` This application is made in co _ / ; or a permit to construct and the work herein described mplience with County-Ordinance No. � J08 ADDRESS AND LOCATION.Uyr Owner's Name Address - 3 <_ _ -------€f __. e Z__21 Phone_ Contractor's Nama_-- --- - -- ---------- •- -•------•----•---- -------- -------------- ------ ---- Installa+ion will serve• - -•-------------------- ee 0 Residence ------------ • ❑ Apartment Ho se ---- --- -- -"----- ------ Phone.--"___-- Number of living units: "'~`- ❑ Commercial --�-------------•-----.- --.--"- Number of bedrooms __'_`_ ❑ Trailer Court ❑ Motel Wafer Supply: Number of baths ----- ____ Lot size ❑ Other Public system ❑ Community system Character of soil to a depth of 3 feet: SandGrave ❑ Privafie �pfh to Wafer Table ❑ Gravel �---- "ff.Previous Application Made: Yes ❑ No ❑ Saridy Loam go Clay Loam ❑ Clay TYPE OF INSTALLATION AND SPECIFICATIONS: Construction: Yes ❑ NoEj ❑ Adobe❑ H,ardpan [] (No septi'tar cesspool permitted if public sewer is available within 200 feet. N Septic T ? is a ) D ❑ � �- nearest wei(-----------------Distance from foundation_________ No. of cor� ` partments_-.----------------..-- .Size................................Liquid depth-- Capacity--------- t1 -------Material------------------ ................ Disposal Field; Distance from nearest well liO' -------------- --- ' Number oi_iines_ Distance from foundation /!� r C -------- r -- Distance to nearest lot Line T r Length of each line,l(®J ] 74�Width of trench "-- •f Type or filter material_.__ ' Seepage pit: Distance to nearest well_._______ Depth of filter material_-_ _ --- `---Total len fh____ ❑ -Distance from foundation__ g --------------------- Cesspool- -------------------- Number of pits-- ---- --------- --- Size: ----------------- �. T --Lining material_ r --- -----------Distance to nearest lot line__.__.__-_-_ Cesspool; Distance from nearesf well_---"-_____ -_Distance from foundart on Diameter_ :__�, Depth_---___-------- --------- ----- ❑ Size: Diameter----------- w Depth__-------- Lining material---------- rivy: 'Distance,from„nearesf well-- ------- ---- -------------Liquid Capacity- ----------------- ........ -- --gals. I 0 Distance to nearestklof line------------- _ ---------=-�-------"�.-Distance from nearest building_ g--------- - ,p �� -------------------------- Remodeling and/or repairing (describe)_______________ -------------------- -----•---------------------------------•------------------------------ ---------•----------------------- ----------------- ----_- hereby certify that ! have prepared this application and that the work will be done in accordance wit ordinances, S+ fawssan rules amend regulations of the San Joaquin Local Health District. h San Joaquin County (Signed)------ ---------•- � s 8y: , ----•----------------- --------------------•---------------------------- ----------------------- ----•------••----------•-------- towner and/or Contractor) ----- ------(Title)-- - Plot pian, showing size of lo+, location ofisystem in relation to wells, buildings, etc., can be placed on reverse side). E D ME USE NLY APPLICATION ACCEPTEDBY_------ -_- REVIEWED BY. DATE BUILDING PERMIT ISSUED-------------------------- z ----- - ---- ----- ------- ---------------------- -------------------------------------- ----------------------------------------------------- DATE Alterations and/or recommendations:--------- DATE..-------- ----------------- -- ------- - -- ----------------------------- -------------------------------------------- -- INAL INSPECTION BY:.--____ Date------------- --- AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street Stockfon, California Lodi, California 132 sycamore Sfreef 814 North "C'• Street , i Manteca, California { '� —2M IO-52 Revised W-2100 Tracy, California