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APPLICATI F ON FOR SANITATION PERMIT Permit No. - ., y k,(Complete in Duplicate) Y Date Issued l/ Applica4-ion is hereby made to the San Joaquin'Local Health District for a permit to construct and instal the work herein described, This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOC ON, •-- Owner's Name ---•-------•-•-- A ----•-"------------- - - -----4 ------ Address�--I----------- Phone . �- -•� ----- - -- - --- --- -- Contractor's Name , " __ ----------- Q . .- 1J --------------------- -- ------------------- Phone- 7� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Cour} ❑ Motel Other ❑ Number of living units: N bar of bedrooms Number of -baths - `` Water Supply:Pubfic..system Commvrrit -s stem- �- Lot size f�_-Q"-�__�-� .. Y Y ©—•Priva•te•❑•�Depth-to -Water 7able� "r�t-•r � Character of soil to a depth of 3 feet: I Sand ❑ Gravel ❑ Sandy Loam ❑ lay Loam [] Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ No UL — New'Construction: Yes 0 ❑ TYPE OF INSTALLATION AND SPECIFICATIONS-.- o ❑ (No septic tank or cesspool permL{ itted if public sewer is available within 200 feet.) Septic T Distance from nearest welt----------------- Distance from foundation._ --.-____---"- No. of compartmerits-.---�---- --- --------------------------------- •--- Material ---•--•- �-------- '-------=----------------- --------Size------•-------•- - ---_---Liquid depth------ --- --=Capacity--------- - - Dispos�Field�- Distance from nearest well-- --Distance from foundation----------_---_-- Distance to nearest lot line--_--_-__-_..--. r Number of lines _----f-_-------,- ------------------- Length of each line ----------- Width of trench - Type or' filter material---_---^ --^ "#Depth of filter material__- -------- ----------- - Totallength_----------------------------------------- ------- ' _________ __ Seepage Pit: Distance to nearestwelly--------------- Distance fr Ifo anon__. _.- Number of its. —I-•-- Distance to nearest to ne- f p Z .�_----__.Lining .maferial_ Size: 1r --_ °?" Cesspool: 4.f�-=---- Depth"-' p Distance "from nearest well ----------------- Distance from foundation Size: Diameter-- _ ---. Lining material" = 1 . Depth --------------------------------Liquid Capacity---------------------------- N Privy: Distance from nearest well--�---__-.-_--___--____ gals. -----------------Distance from nearest buildin i-------------------------------------- ------------ ` ❑ -Distance to nearest!.lot line _.�`----' g--,emodeling and/or repairing (describe):___ *_--_.-_-_-` -•- --- --- •----------•---•------ ----------- ------------••---•---•----------------------------- } ------------•---- ---------------•--••--•----•-------------------- --- -- -- ----------------------------------------- -- - - -------------------•------- - f`, ----------------- --------•----------- --------------------•------------------------------- ereby certify that l have prepared this application and at the work be done in accordance with San Joaquin County ordinances, State laws, and rules and re lations of the San J aquin Local,Health 'strict. (Signed)-_ , -6 - .dGf (Own and/o ontractorl - r - (Title) ----.__k • r------------------- -- {Plot plan, showing size a lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)- - ---•-- --- --------------- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__--"-__-__---:-_ REVIEWED BY- ---------- DATE •----••- .-' ---------------------- BUILDING PERMIT ISSUED ---------------------- - ------------------------- -- DATE---- - ----------------------------------- DATE-------` ----------- ----------- I -----------------o--r recommen ations. ----------------------------- -•------•------- -------------------•--------•---•---------------------•-------------------------------------- ••------ ---------------- ------•---•--------- --•--------•-- ------- -- ------------------------- ----- •---- FINAL INSPECTION BY------------- - Y� S� - 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 ; - Revised W-2100