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APPLICATION FOR SANITATION PERMIT Permit No. '7!. ' (Complete in Duplicate) '3( 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 made in compli nce with County Ordinance No. 549. !6 w 3 AQDRE55 AND LOCATI __- _� �- -_.:Owner's Name_______________________ "�' .. Phan4- JOB --- f Address-----------•- -------- Contractor's Name------------------- _-�____K--------- -------------------------------- Phon ----C?_® Installation will serve: Residence Zj_�partment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j____ Number of bedrooms -_ Number of baths _/____ Lot size _j- 2-4 ----�-------------- Water Supply: Public system [�Communify system ❑ Private ❑ Depth to Water Table ft. •�L- \ Character of soil to a depth of 3 feet: Sane El Gravel Sandy Loam Clay Loam El Clay ❑ Adobe [f�Hardpan E]Previous Application Made: Yes No New Construction; Yes El No E] ❑ �--��=— Ou TYPE OF INSTALLATION AND SPECIFICATIONS: ~ (No septic tank or cesspool permifted'if public sewer is-available within 200 feet.) ti Distance from nearest well_________________Distance from foundation______S_____-___-_.Material------------------------------------------------- No. of compartments-------_- ---- ----- -----size--------------------------------Liquidfdepth--------------------------Capacity----------------------- posal field Distance from nearest well-f_______________Distance from foundation---- ------------Distance to nearest lot line_________________ Number of lines-------------------------------- -Length of each line--------`------i_____-----.Width of french----------------------------------- Type of filter material_________. ___.-___ Depth of filter materia-----------------------Total length--------------------- -_-__-__-______.__._ Seepage Pit: Distance to neares well__ (_Distant f fo dation___!__ ..___.Distance to nearest lot line_____A-______� + Number of pits..- _________.___:_Lining material-______ _____________Size: Diameter__- 1�_____Depth-----,, : .� + 0---------------- Cesspool: Distance from nearest well-______________Distance from foundation______ ____________Lining material------------------------__--_____-___ Size: Diameter Depth 01 ` I----------.Li Liquid Capacity ---------.gals. ❑ P -- 9 P Y Privy: "r Distance from nearest-well--------------= ----------------- Distance from-nearest buildings.-;e=---------------___--=,_.-,--::-=:- � ❑ 4 Distance to nearest lot line..- - = Remodeling and/or repairing (describe):________________________________t ------ ___-._.---.-_------ � ----------------------- - ----------------------------- ------ ----------Pp ----------- --------j ---------------------•--------------------- -------- •- - --- -------- I hereby cerfi fha I havred t applthe work will be done in accordance with San Joaquin County ordinances, State s nd ry,lregul ons on Lac I H alfh District. i (Signed} Title_ �,----------------------- ontractorJ { BY•----•------- - ( ) (Plot plan, showing size of lot, location of system in re f' n +o wells, building etc., can be aced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------•------------- DATE---------�,---- r`5 REVIEWEDBY----------------------------------- ----------------------------------------------------------------------------------------- DATE----------- ------------------•---••--•-------•------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations--------------- --------------------------------------------------------------------•-----•--------------------------------------------------------------------- •-------------------------------------------------------------------- -------------------------------------------------------------------------------------•--------------------------------------------------------------- ------------------------=--•----------------------------------------------------------------- ----------------------------------------- -------------------------------------------------------------------------------------- ---------------------------------------------------------- ------------------------------------------- ------------------ --- ---------------------------------- ----------------------------------------------- 6 FINAL INSPECTION BY------------- ------ ---•---------------- Date----- f� ---------------- 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