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APPLICATION ON FOR SANITATION PERMIT Permit No. ------------ (Complete _.______(Complete in Duplicate) _( Date Issued ____-/I_71, s -� f Application is hereby made to the San Joaquin Local Health District for a permit fo construct and install the work herein described. This application is made in compliance,with County Ordinance No. 549. JOB ADDRESS AND LOCATION______l ___�__. ,�j1U�' I �_ ---- --- --- --------- --- ------------------ -- Owner's Name------------ ----4. I` -----.Phone--- -0-10---------------- Addressi ------ ` ------ - -----•-------------------------------- kContractor's Name---------- -- ------------ ------- ----------- --------------------------- -----------------;_ Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �} Number of living units:m Com""ber of bedrooms_ _ Number of baths-=X_ Lot size____'___- � l1 Water Supply: Public systemunity+system -❑ Private ❑ Depth to Water Tabl.-4-- ft. 1 Character of soil to a depth:fof 3 feet: Sand ❑ -Gravel ❑ Sandy.Loam ❑ lay Loam ❑ Clay ❑ Adobe Hardpan ❑ 4 Previous Application Made: 11 Yes ❑ No A-_�New Construction: Yes o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distarrce',from nearest well_________________Distance from foundation------------ -. =Material_______________ No. of compartments-=------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Fie : Distance.from nearest _wen _____Distance from foundation_/__V__------.---Distance to nearest lot ine___��_________ Number of fines-- -- �`' __-- � Length of each .€ine-_-- --------------Width of trench ....;-------------------------- Type of filter material_ c__Depth of filter material___-_ _____-.__Tota! length______ (f ____________________ Seepage Pit: Distance`to nearest well/&V----------Di nce from fou ion ! —Dist nce-to nearest lot line____ --- Number'of pits_- .......Lining ma erial '_:S' e: Diameter---- ----- --------Depth--- jCesspool: Distancefrom nearest well__________:_____Dis nce from fou tion--------------------Lining' material____________________________________ ❑ Size: Diameter--------- -=--------- --------------Depth------------------------------ -- Liquid Capacity gals. r� Privy: Distance'from nearest well_________________________________________________Distance from nearest building �1 ❑ Distance..to nearest lot :1ine---_____-- _ -----------------------�-----------------------------------------------------------------------------------•------------------------------------Remodeling and/or repairing (describe):_____ ____ __ ____ _____________ ----- _----------_-------- ------------------------------------------------=`- ------------------------------• ----• 1 -----------------------------------------------------------------------------------•------------------------------------------------------------------------------------- ----------------------------------------- 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, nd rules and re ulaf ns of th San Joaquin Local ealth�Distriet: (Signed)-------- Own and/or ontractor) BY:------- -:-- -- ---- .-----�L� -- ---------------------- ---------------------- (Title � ---------------- (Plot --- ---------------- (Plot plan, owing size of lot; location_of-"system in relation to wells, buildings, etc., can be placed on reverse side). - - H FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY r' ----------------------- ---------- ---------------------------------------- DATE-1' REVIEWEDBY--------------------------------- -- ------ ---------------------------------------- ----------------------------------------- BUILDINGDATE - Altert ons and orTrecommp n'' DATE ��------------------------ / dations--------------------------------------=----------- ------------------------------------------------- ---------------------------------------- --------------------- ___________________________________.,___-..__-______i-----------------------------------------------4 ________________________________________________ _"__ • 1.M r FINAL INSPECTION BY: IU - ------ ------------------------- Date---- ------------------------------------------------------ 1 SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stock+on,"California i Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 i! '