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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued .---�l� S Y Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work This application is made in compliance with County Ordinance No. 549. herein described. q JOB ADDRESS AND LOCATION- _--P _fl__- �? --------------------------------------------------- Owner's Name - = J1� a Phone o� '� - ------ - - -- --- - - - ----------------------- Address -_ C. .,. _ Contractor's Name---------- lid ------------- ---- rz�- - _- Phone- /-.-T- - 0 Installation will serve: Residence..Apartment House ❑ Commercial Trailer Court ❑ ❑ Motel ❑ Other ❑ Number of living.units: _- Number of bedrooms - f E �- Number of baths --- Lot sue ____- Water Supply; Public system Community system '❑, Private ❑ Depth to Water Table4_, vft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No157 Construction: YesoNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: \ (No septic tank or cesspool permitted if public s Iwer is available within 200 feet.) Septic Tank: Distance from nearest well, Distance ation_/0_ ,� Mate y"ai -------------- ------ ,� No. of compartments_-____- :______-""_$1Ze, -Liquid de _,2��_ -----Capacity )-" .c�o Disposal Field: Distance from nearestwell_ — I ' istance from foundation __ ___-__ Distance to nearest lot line-____-_, ___ Number of lines----------------- _f` _Length of each line------—` f _ Width of trench-"_ ___-.- Type of filter material--- _A� .S-Depth of filter material---.__-,� ---------Total length---_--- �_-----"-- Seeps e Pit: Distance to nearest weii__4VQyu,__._Distance m and tion_ ! _`_-------Distance t barest lot line�.?� Number of pits-------- ------------Lining material----� �� _ ize: Diameter--- s} . --d De th-- p a--------------------- Cesspoal: Distance from nearest well_--"_-----"__.-.-Distance from foundation-_______--------__ Lining material-------------------_----___ { ❑ Size: Diameter------ ----------�" ---------�- -.Depth ------------ ------------ ------- - -- ----Liquid Capacity----------------------------gals. Privy: Distance from nearest well.__----__.-------------"___ Distance to nearest lot --._--.____"____Distance from nearest building❑ line_-"__.----.___------------------- Remodeling and/or repairing (describe)-------------------- ---------------------------------- ----------- ----------- ---------------------------------- ---------------------------•--------------------------------- -------------- -------- ___:---------"-------------------------------------- -----------------------------------------------------------------------------------------•---------------- 1 hereby certify that I have prepar d this application and t t the w rk will be done in accordance with San Joaquin County ordinances, tate I s, an rules andi gulation of the San J. quin Loca ealth District. (Signed)-___ .... , ` ''ma c r-� ....... .. --------- ) -- -- -- --- -- - -----�-- --•-e�----- ---------- -- tract C n or (Title) ' (Plot plan, sh ng size of.lot, location of sys em in relation to wells, buildings, etc., canbe ,laced - _______ p averse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------lou- DATE_______ __ _ __ ! V REVIEWED BY---•----------------------------------- - / - ----------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------•----------- ----------------------•------------- ------------------------------------------------------------------------------- DATE--------- ---------------- Alterations and/or recommendations:_ ------------------------ " " ---------------- -------- ------------------------ ------------------=------------- -- f ----------------------------------- ------------------------- 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 ES-9-2M 8-51 Revised W-2100 a