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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �� Date issued ---7/5f_Y Application is hereby made to the San Joaquin oca Heal istnct or Z—ja permit to construct and install the work herein described. This application is made in compliance with ounty Ordinance No. 549. JOB ADDRESS AND LOC TI - '04r Owner's Name_________ Phone. Address------ �1 Contractor's Name---------- ----------------------- -------•---------------- --- Phone ------------------------------------- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-f___ Number of bedroomsvZ__ Number of baths,___ Lot size _ J' �� --------•-------------------------- Water Supply: Public system f] Community system Private ❑ Depth to Water Table :VOS4�_- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam El Clay El Adobe 9-1vardpan ElPrevious Application Made: Yes [j No ZR"New Construction. Yes 9hlo ElFHA/VA: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) I Septic Tank: Distance from nearest well- .vDistancf om foundation___ _-----.--- r No. of compartments----- C X_Y_a_,_._Liquid depth__ r' Ca p ty .s- , -- - ------- -- Disposal Id: Distance from nearest wel! 'Distance from foundation_____�X__®__ _.Distance to nearest lot liner_ s Number of lines________. .__ en th of each line_______ - - g --.Width W,dth of trench----��--•-------- --- c� Type of filter materia Depth of filter material---fin --------Total length----f-a-i) Seepa Distance to neares# well - - �f .C,_--Distance from fo dafion___! __--_.Distance to nearest lot line__4___-___ 'LJ' '�.► Number of pits....... .----------Lining material_ , _-Size:-Diameter-- 9%?-----------Depth------A_t4_-1 N Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materialEl Diameter------------------ ------Depth--------------------------------------- - --------Liquid Capacity- -------------•--------- gals. Privy: Distance from nearest well-_____________________ ____.__._Distance from nearest building---_ ❑ Distance #o nearest lot line--- ------ - - ----------------------------------------- Remodeling and/or repairing (describe):--- --------- r ------------------------------------ ------------------- -----------------------------------------------------•-------------------------•--------------------------------------------- ------------------------------------------- --------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and r es and regulations of the 'San Joaquin Local Health District. (Signed)--------------------- r ----- By: ----- ---------- ------------------------------------------(�� Contractor) or) ---------(Title)-------....00 ----------------- ----------- ---------------- --------- ----- at plan, showing size of lot, locatia system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE l ------------ REV -- --------------- fEWED BY------------------------------------------------------------------------------- --------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:----------------------------------------------- ---- --------------------------------• ---- --------------------------------------------------------------------------------•------------------------------------------------•------------ 1fNAL 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-9-21x1 , Pevisea 1.57 F.P.CO.