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APPLICATION FOR SANITATION PERMIT Permit No. __... (Complete in Duplicate) �� Date Issued ....__ Z. 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. JOB ADDRESS AND OCATION. ------ ------ i9 -�WW�'y��2� --- - ---------------- Owner's Name -��- •------ - - -. ". --------- Address.------ 11a->i-Pte_... = ------------•-----•----------- --•- ---------------------- ---------•------------------ Contractor's Name --'--..� i,: ----------- Phone. . Installation will serve: Residence �partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I---__- Number of bedrooms eZ-_ Number of baths 9- Lot size , �D D ------------- ---•-------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Sd ft. Character of soil to a depth of 3 feet:, Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe El'-H-ardpan ❑ Previous Application Made: Yes ❑,. No New Construction: Yes ❑ No R-1, TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tic 7��ank: Distance from nearest well-"--------- -----Distance from foundation----------------- ---Material ..____. if No. of compartments------------- - -- ------Size--------------------------------Liquid depth---------------- ---------Capacity-••------- ---------- isposal eId: Distance from nearest well---- Distance from foundation--------------------Distance to nearest lot line-- __-__------- ❑ Number of lines-----------------....••--_---------Length of each line_------------------ -----------Width of trench- ------ ------ ---------------- 1 Type of filter material---------------------:---Depth of filter material-----------------------Total length--------------------------------•--------- Seepage f: Distance to nearest well_ J----Distance fr foundation-__ 4_/_._ i an�e to nearest lot line- -S1 -------------- ' Number of pits... ___-/'------.-_-Lining material-S �.---Size: Diameter__� Depth_--v---S`/ Cesspool: --- Distance from nearest well from foundation..._----------------Lining material Size: Diameter--- ----------------------------=--Depth------------------------------ ---------------------Liquid Capacity -------------------------.gals. Privy: Distance from nearest well________________________ ---.___Distance from nearest building N) Distance to nearest lot line---------_---_____--..-.--_-,_- Remodern 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 law and rues and rns of the San Joaquin Local Health District. (Signed)---------------- -Jl.c 4-n -------------------- -------------------------------------= {O ner--an-d/-- or Contractor) Titl ------------------------------ ---------------- By= ------------ .re-�-----_�-tJ-- - - - - - - - -- - - -- -- - - -- ----- -- - --- -- ------- ----- (Plot plan, showing size of lot, location of system in rela n to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------------ - --- ---------- --------------------------------------- DATE-----✓- REVIEWED BY-------------------------------------- - -." . - --- --- ------- -------------------•---------------•----------------- ---'DATE---------- --------------- � - BUILDING PERMIT ISSUED --------------------------------------- ------ DATE.----------- ` Alterations and/or recommendations:_{----------------------- . ----------------- - ------ --------------------- ------------------- -------------------------- -------- --- FINAL INSPECTION BY:__ - --�--------------------------------•------- Date-- �.�."----�---- .-- ---:---- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streef 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California ' I Lodi, California Manteca, California Tracy, California ES-9-2M 145446 ATWOOO 13-54