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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) - Date Issued .__? Applica-ion is hereby made to'the San Joh aquin Local Health District for a permit to construct and install the work herei This application is made in compliance with County Ordinance No. 549, f n described. JOB ADDRESS ND L CATION.._____ Owner's Name----- +� ------- Address- - -~-r---------- -- 3- Contractor's Name.-. _ _ -- ---`----•------- .. '. -------------•-----•--- --------- Phone- Installation will serve ---- ••-•- �• - •-•=-------- ,Residence El Apartment House p Commercial El Trailer Court ❑ Motel ❑ Other [ U � Number of living units: -------- Number of bedrooms -------- Number of baths ______-. Lot!sizec ► Water Su I "Public,system ---------- --------` " PP Y: y ❑ Community system ❑ 'Private ®...Depth to Water-Table 4J--'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay LoE3am . Clay Adobe ❑ Previous Application Made:. Yes ❑, No [Alf New Construction: Yes 59 No ❑ . Hardpan E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic.Tank: Distance from nearest well-.- 5! —---'Disfance from foundation 1O ' " '' + r No. of compartments.-_- o. ---- t --- �---•---p--�-y-- Ma..Material------------- Size ... = -------Liquid depth- �� CapacitY------ Disposal Field: ---- J1 Distance from nearest well___. _. oe .._Distance from foundation__ ___f> _____Distance to nearest lot line-----Number of lines______ - --- (---.__r• Width of french.----•_�,_ `( p h of filter material----------- eng#h of each line_____-1_Qo-_-- Type of filter material__:__ _2_--__�__ _ e # � '� -- " � _ - -1.�. ,:.,�,. �., -------Total length-----------1-----b- .------ Seepage,Pit: Distance to .nearest.well----------------------Distance_from foundation_____.___.:._._Distance to nearest lot line_-_____-_______- .- . ❑ - Number of pits-------- ---- -----Lining material------------- ---- ----Size: Diameter----------------------- .Depth- ---- ---------•-----•----C - esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ Size: Diameter-------------- ---------------------Depth------ ----- ----- ---- ------ Liquid CapacitY_.-- ! � ,71� ta ;' . .. x � j �' 'f^•r-.r k Y•r• y� w -I- �__.. ..._ ___ ______ s. .� Privy. Disnce from nearest well------ __ ------`--'----1--- - ----------Distance from nearest building__ El Distance to nearest lot'line- -:--,--:--4- ------------------------- Remodeling and/or repairing [describe}:_'__ .. -____----_------ ------------ c r ----------••----•--- ----- ------ a =-- ----I -------------•-------------------- •------------------------------ --------•------•------- ----------•---------- =-•----------------•-----------------------------------------------------------•---- 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)-- - i .� Jk ( - -- --- •------------------------- Bwrser�nel/•eF C tr t i By: = $- s••- ----- ------•------------ { on ac or] ------ -[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______ _ REVIEWED BY I ___ _________ --------ti--=-----'- ------------------------------------------------ DATE.__ .- BUILDING PERMIT lSSl1ED__. 1 - % ------- -- - - ------------------------------------ DATE-------•------------------- - :... ----------------- - - ----- -----------------------------------•-----=---•---- DATE---------•------------- Alterations and/or recommendations:__________________ -'- -_- - --••- ---------------- ---= ---- ------------ -------------------- --•-------------------- FINAL.r INSPECTION BY: -4- 41--_ __ - - . ----». Date_-.-� •��° -------------------------------------------- j5e '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 +.