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APPLICATION FOR SANITATION PERMIT Permit No. . (Complete in Duplicate) _ - Date Issued _11 71,-3 Cv,,/'-/App,ica ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her This application is made in compliance with County Ordinance No. 549, esn described. JOB ADDRESS AND LOCATION-----/ 'I?Ad , Owner's Name -------------------------------------------------- ------------- Address--- 2 .- 4N [3 --- ----- --------------- --- - --- ---------Phone------- -�--- _ ------------------------ Q Contractor's Name -- •---•----------- ----------- -------------------------•• -----------•-------------------------•------- --•--------------------------�fl ---------------- - ---- - ------------ ------ -------------------- Phone-- -�9- Installation will serve: Residence --- ----`- -- ---- [� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/_ Number of bedrooms - ---_- Number of baths -l.--- Lot size ----+��" � _ Supply: Public system ,)( Communit system �� ------------------ Water ------- Y Y ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes ❑ Nojig- New Construction: Yes,JK No TYPE OF INSTALLATION AND SPECIFICATIONS: E] (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well � 01�E-_Distance from foundation_-JO. -I ----MatOrial------------------ --_G__- No. of compartments_- -- �5--------------- --------------- ----- ------- Size -�/-�-�-- '" Liquid depth_a �_..- -----.Ca Capacity------ Disposal Field: Distance from nearest well N p yOp Q .-Dist from dation_-I-D'__-__----Distance to nearest lot line----S: IV Number of lines--------1------------r_---_ _--Length of each line---70-----------------Width of trench-----!_Z K-- Type of filter material--1-��_--R ----Depth of fitter material---_-��" �j .fes ----Total length------7x�--Pit: Distance to nearest well -------Distance from foundation------------------- Distance to nearest lot line-_--.----_--.--- ❑ Number of pits----------------------Lining material ----------------------- Diameter--------------------------------------Depth_------- ------------ Cess ool: ---_--_---_ ❑P Distance from nearest well-----------------Distance from foundation-_---.__-..__------.Lining material-- _-_-_ Size: Diameter-------------------------------------- ------------ Depth Liquid Capacity --------------------gals. Privy: Distance from nearest well-------------_.-_ --__-_...- _.. Distance from nearest buildin 13. Distance to nearest lot line---------------------------- g------------------------------------------ F1 - ------------------------------------- - - Remodeling and/or repairing (describe)- -------- --------- -------------_-_,.-___ ------------------------------------•-----------------•---------•--------------------------------------------------------------------------------------------------------------------- I hereby car fy hat I haverepared t ' application and that the work will be done in accordance with San Joaquin County ordinances, State laandrule and reg ions C7,7' f + e Sa oaquin Local ealth District. (Signed)-----•----- �- n --- -------- By:--------------------------------------------------- ----- ------------------ Title on ract # or (Plot plan, showing size of lot, location of system in rel n to wells buildin ( ) � e etc. can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- REVIEWED .. ------ ----------------- --------------------- ---------------------------------------- DATE ----- ---- - ----- -- ----------------------------------------------------------•-------------- BUILDING PERMIT ISSUED DATE- 0 -------- � Alterations and/or recommendations- ------------------------------- DATE--------- 0----------------------- - _ ------------._- --- ----__ .__.- ` ----- ------------ ----------------- - -- ------------------ FINAL INSPECTION BY:------------ V_ 1� iy ry - --------------------------- 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-9-2M I0-52 Revised W-2100