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APPLICATION FOR SANITATION PERMIT Permit No. �. (Complete in Duplicate) Date Issued Applic&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 Ordinance No. 549. JOB ADDRESS AND LOCATION_.__ i - - ` -- d [�/2 Owner's Name /-G __49 ----------- Address ------ Phone-------------- `'�l�•• /•- -- ---------- -- � on rector s Name- - ----------------- f -•-------•---- --------•- ----------------------------------- El Trailer ------- -- ---- ---------------------------------------------------------- Phone----- Installa#ion will serve: Residence A artment House ❑ Commercial Trailer Court Number of living units: --__ _- Number of bedrooms ___a" E] Motel ❑ Oth--e-r--E]------- --------- , Number of baths l_____ Lot size _ 6-a-")<" /_S__'•_-_�_ __ Wafer Supply: Public system ❑ Communitysystem Yem ❑ Private, . Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe„ ' Hardpan ❑ Previous Applicafion Made: Yes WNo ❑ New Construction: Yes '' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Distance from nearest well `-5�--_Distance from fouw ation____/P-------Mater•ai_____" No. of compartments---- £ ------Size--- -�� } ` Liquid depth__. �J Capacity--- �C� is os I Field: Distance from nearest well_ Distance from foundation___-_/� --Distance to nearest lot line___-___-S_-• I Number of lines---------""""-- --"----- --------Length of each line-----------_6.8 -------- Total length__________".____-____",�"LQ_ Seepage Pit: Distance to nearest well__________"-"- " --- ____-Distance from foundation---------------------Distance to nearest lot line_____--._______. ❑ Number of pits----------------""---Lining material----------------------Size. Diameter_--------- R Deptn--- ------------------------ Cesspool: Distance from nearest well__-_---__-__--__Distance from foundation----------- ---_-Lining material____-_-_._-"-""_""-__"""_ ❑ Size: Diameter-------------------------------------- Depth----------------------------- ------ - -- ------- --Liquid Capacity-- --------- els. rivy: Distance from nearest well--------- "_--_" -""__ Distance from nearest building -------- - _l ❑ Distance to nearest lot line------------------- -- -- " g Remodeling and/or r a ring (describe):"_-- ""-- -- ------------ -- ----------- ------ ---- ________ __ ------------------------_-----_ ______________________________________________________________________"_______-___-__ ._ 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 rul s and regulations of the San Joaquin Local Health District. (Signed)_ - l r; � ------ ---- -- ------(Owner and/or Contractor) - ------------------ --------------------- -------------- (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-- ----------------- C REVIEWED BY_ - ,tri _ ------ DATE I �..- _ --------- ------------ ----- DATE BUILDING PERMIT ISSUED ---- ---- -------- - ----- Alterations and/or reco mendations:_-------- A E - ---" ............. •------ ------ -------------- 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 r Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100