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APPLICATION FOR SANITATION PERMIT Permit No. ._ _; _7 7. (Complete in Duplicate) Date Issued Application 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 compliance with County Ordinance No. 549. JOB ADDRESS AN�Dj LOC..A.TTIION.... Owner's Name-------- - ------- ------------------------------------ ------ ---------------------------------- -- Phone. J a Address........... / , ---------------------------------------- ----- "_ , 1£---7.-- , Contractors Name =-----.--_-"J-- - •,w. Phone Installation will serve: ResidenceApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Nu�er of bedrooms __I____ Number of baths .__L Lot size ______ 5'_42__X__/6�--______________________ Water Supply: Public system EjIeOCommunify system ❑ Private F Depth to Water TableJ�. ftS Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam ❑ �ClayLomE] Clay E] Adobe HardpanPrevious Application Made: Yes E] No ow Construction: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic T k: Distance from nearest well____.0-------Distance from foundation------fQ__f---------Material---------- 1 ?+�___________ No. of compartments_..__...___2____------Size------5_X_-`_X__3----._Liquid depth-----_----9?.......______Capacity-----�-5�-------- 1ti Disposal Id: Distance from nearest well-------11.1)------Distance from foundation_7---I>Sr.i-----Distance to nearest lot Iiine_______-S �- 'V Number of lines--------------__-------------------Length of each line____(p6A_311___--_-_--Width of trench_.___ r Type of filter material-------)l�_p__.____Depth of filter material-------/�r_"-_______Total length______ _�_ __ . - See pag it: Distance to nearest well-------.SA----------Distance from fgundation------ �6_`_._.Distance to nearest loft line__ ` Number of pits----------- .__________Lining material------- y��lf-----Size: Diameter__.._------ -`-_-Depth__.-..._k�_------------- Cesspool: Distance from nearest well-----------------Distance from foundation....--------------- Lining material-_..____- ------------------------- El --..-.-.--______._____❑ Size: Diameter----------- ---------------Depth------ ---------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------- -----.-.----------.----------Distance from nearest building------------------------------------------ ElDistance to nearest lot line---------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe)-----------------------------------------------------••--•-----------------••-----------------------•-------------------------------------••----------- -- ---------------------------•------------••---------------••--•---- ----•---•------------------------------------------------------------------------- -------------------- I hereby certify that I have prepared this application and at the work will be done in accordance with San Joaquin Count ordinances, St , and rules end regu ions of the an aquin Local Health district. (Signed)------ ----------- -------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------------------------- ------------------------------------------------------------(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------------------------------------------------- DATE-------------- -— REVIEWED BY DATE --------------------- ------------ ---�ct– --------------------------- ---- BUILDING --------------------- ---- ---- BUILDING PERMIT ISSUED----------------------- ----•-•--- ---------------------------•--------------------------------------- DATE Alterations and/or recommendations-------------------------- - - -----------------------------------------------•-------------------------------------------------------- ----------------- ---------------------------------------------------------- -------------------------------------------------------------------------------------------------------------- ------------------------------ ----------------------------------------------------------------•-------------------------------------------- ----------------------------------.----------------------------------------------------------------- --- FINAL INSPECTION BY:---- ------�---------------------------- Date....... �^ ----- - S- -`S �.. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton,. California Lodi, California Manteca, California Tracy, California ES---9-2M �0-52 Revised W-2100