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APPLICATION FOR SANITATION PERMIT Permit No. . �. . (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 mad3eli6 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_.•___-__L7l.a_______ Owner's Name------ - 49 y-y-- __10.At' _l ------- one----- - ---- ---- - - -- - ------ - ----------._ Phone--------------------- Address ---------------------------------- Contractor's ------------ Address-------------1-7-�1 ...•--• •------ _ ` Contractor's Name...... �_. __. A _• ________________ Phone_Y._ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___I__ Number of bedrooms __,X Number of baths ---I--- Lot size _______ ..___ ca---------------------- Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table --------'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J�d Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta)� ance from nearest well-----------------Distance from foundation.----------..------.Material. ------.--------------------- ❑ of compartments-------------------------Size-------------•----------------- Liquid depth Capacity ------ Disposal Field: Distance from nearest well.----------------- foundation_.-___--___:____.._.Distance to nearest lot line--------------- ❑ umber of lines-----------------;-----------------Length of each line- Width of trench----------------------------------- Tape of-filter material----------------------__Depth,of filter material-----------------------Total length________________________-_______________ \ Seepage Pit: Distance to nearest well------- -_ / Distance from found tion_____../CefDistance to nearest lot line_-_�_-_____ Number of pits-------�_.______-___Lining material_G_� !Q�ize: Diameter-----33-------.---.Depth____- Cesspool: Distance from nearest well-___________'_Distance from foundation--------------------Lining material----------- ❑ Size: Diameter--------------------------------------Depth-'- -==-- ----Liquid Capacity----------------------------gals. Privy: Distance from nearest well--_._.____--___-____.-_._ --------------Distance from nearest building 1771 Distance to nearest lot line -_ - -_ ------------ Remodeling and/or repairing (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 rules and regulations of the San Joaquin Local Health District. _ (Signed) .�-/� --1_`�"-_ ... ---------------------------------------- ---------------------------(Owner and/ C or ontractor) By� - -- ------ (Title) - --- ot plan, s owing 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------------- DATE - ------ -------- - REVIEWED BY ---- - - DATE---1--J -------- ------ ----------------- BUILDING PERMIT ISSUED----------------- ----- -- h--------------------------__ DATE--- = Alterations and/or recommendations_ __________ --------- ----------------------------------------------------------- ------------------------------------------------------------------------------------ -------------------------------•--------------------------------- --------------------------------- -----------------------------------•-- ----------- .-.___-_4___________________________________________________________________________ ________________________ FINAL INSPECTION' BY:.. ---- -...3----- ----------•------- 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 Mentees;;#'California ?racy, California ES-9-2M Revised W-2100 i