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APPLICATION FOR SANITATION PERMIT Permit No.z/_!-.R Y (Complete in Duplicate) — Date Issued �_�_ `�___.��j .__ Application is hereby made to the San Joaquin Local Health District for a permit to construct an i a the work he�ei� des ibAr�. This application is made in compliance with CoVn, Ordinance No. 549. w+ > r ,L Z7 0 JOB ADDRESS AND LOCATION-------• _:. � ,1 ---- -------------- --------------------------- ____.____'.- ------- Owner's ---X ------------- f Owner's Name------ ------- ="" Phone f on Address..-----------------------� " �',�� ` -� k- Contractor's Name 7 -------------------- ----------------------------- _ Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms w _ Number of baths __)___ Lot size --- __1 "Q Water Supply:`Public system'[] -Community system ❑ Private 200'-Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑.G a I ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ Now-Construction: Yes ge'No ❑ r TYPE OF INSTALLATION AND SPECIFICATION rseptic tank cesspool lP permitted Wewithin 200 le _ - •)_ dethLiquid ------- ----�-CapaciSeptic Tank: Distance from nearest ell--- stanafromfondaio--1 �________-Mateal No. of compartments-.-_. -----Size- �y-- - ( �� > Disposal Field: Distance from nearest well---- -- stance from foundation----0-_' ,Distance to nearest lot liner_____ Number of lines---------- Length of each lin ----Width of french------- __ ` . Type of filter materia$57,- limit y .Depth of filter material_____ ___ _________Total length________.-. _______ .7 w Seepage Pit: Distance to nearest well_.___________________Distance from foundation_______. ______-__.Distance to nearest loft line-----.------------ Z El Number,ofy pits---------------------Lining material---------- ----------..Size: Diameter-----------------------Depth------------------ • Cesspool. Distance from nearest well-----------------Distance from foundation------------- -----.Lining material-------------------------------------- ❑ Size: Diameter----- --------------------------------Depth----------------------------------------------------Liquid Capacity-------------- -------------gals. Privy: yl rom nearest well_________.____.r_ . ---------------------f__Distance from nearest buiiding.~___________________ Distance p - _. ❑ Distance to nearest lot line_____-._________________ ------------------------------------ Remodeling and/or repairing (describe):----------------------------------------------------•---------•-----------------------•-------------•---•------- ------ • t • .. f- I hereby certify that-1 Neve prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and pules and regulations of the Sart Joaquin Local Health District. (Signed). '-.....-K, ')---------------------------------------------------------=----------------------Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title) (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 APPLICATION ACCEPTED BY--- ---------------- REVIEWED --------------REVIEWED BY :----------------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------ �-------- ------------- -----------------------------[-A---d-- -------------- DATE -A-- TE Alterations and/or recommendations:- --- ----------------------------- - . -- --------------------------- ---- -- --••-- - --- - -------------- ------ ------------- ------------------------------------------------------ . --- - - -------- -----------------�--j----------- --- - ------------------------------------------ ------ --------------------------------------------- - --- ---- --- ---- ----------------- - - �T 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 � x ES-9-2M i0-52 Revised-W-2100