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APPLICATION FOR SANITATION PERMIT Permit No. Of.- - (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 Ordyina e No. 549. JOB ADDRESS AND AT N_____-"" _ v Ph _+ 4� � : Ph( Owner's Owner's Name --._----- -- --•--,•--------------------------------- --------------------------- ------------------ Address.- -- -/-- Address._ _ Ph •- -- ----- --f one Contractor's Name"._._-__"_ __ Motel Other ❑ Installation will serve: Residence ❑' Apartment ouse ❑ Commercials Trailer Court ❑ Number of bedrooms _ Number of baths _�_`- Lot size _. � ------------------ Number of living units: _ ___ I � � ; De th to Water Table& ft. Water Supply: Public system Community system ❑ Privatev❑, p Adob Hardpan Character of soil to a depth of 3 eat: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ � \\ p ❑ Previous Application Made: Yes-E] No New Construction: -YeA-�No Q ' TYPE OF INSTALLATION AND SPECI (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ---------------- Septic Ta k- Distance from nearest well----------------IDistance from foundation-------------------.Material------------------------------- No. -----.---------- --No. of compartments------ ------------ ;Size--------------------------------Liquid depth----------------I--------Capacity.----------------------tR Disposal Fiel Distance from nearest well...____"_-..__Distance from foundation--------_--------""Distance to nearest lot line----------------- �l Q Number of lines------------------------- !Length of each line------------------------------ Width of trench----------------------------------- Type of filter material-----------------__----Depth of filter material-----------------------Total length"""_-"""_._-""""_" ,__ i r ' ""-_Distance m Joufidation"",�p----•--.Dis ante to nearest lot line_"._" Seeps e Distance to nearest we!!__". �- t/ Size: Dia meter- __ Number of pits-- -------------- from foundation kateria ing Cesspool: Distance from nearest well--------------- Distance from foundation_._------ Liquid Capacity ga N F De th---------------------------------- ----------------- Size: q P tY ❑ Diameter------------------------------ ------: p _ E -----Distance from nearest building--------------------- ----------------- I Priv Distance from nearest well--------------------------- Distance to nearest lot line"-_y"`:------------ --------------------------------------------- El , Remodel* and/or repairing (descri 1 - -------------•--- •--------------- --------------- - ------- ------- ----- /`� ----•-----------•---------•-------- ten certify that I have prepared th application and that the work will be done in accordan -------------------- ce with San Joaquin County or finances, State law d rules a r ions of an Joaquin Local Health District. ------_------------- -----(Owner and o Contrac#or) Signed By:-----------•---- ------- ------- _;--- -------------------------------------------------------------------(Title)------ - ` (Plot plan, showing size ot, ocatio of system in relation to wells, buildings, etc., can be on reverse de). + FOR DEPARTMENT USE ONLY . i - DATE--------------------•- -- - ----------- &A_&_; - ------ ------------ y. ��--- APPLICATION ACCEPTED BY.---.----- --- DATE------------------------- - t ... lREVIEWED BY----------------------------------------------------------------- - BUILDING PERMIT ISSUED---------------- -------------------------- DATE ': i Alterations and/or recommendations:---_""_._". ----- d --•- 3 —7� X� FINAL INSPECTION BY:---------------_�- ---------------- � ------------ -- Date SAN JOAQUIN LOCAL HEALTH DISTRICT . no West Oak Street 132 Sycamore Street 914 North "C" Street 130 South American Street LoTracy, California Stockton, California di, California Manteca, California Y An