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� APPLICATION FOR SANITATION PERMIT Permit No. .41'_��_`___�_1..._ y/ [Complete in Duplicate} Date Issued Vo/f�;3 pplicafi n is herebymade to the San Joaquin Local Health District for permit to construct and install the work herein described. q his application is made in compliancewithCounty Ordinance No. 549. JOB ADDRESS AND Q�,CAT N___- r_-3 J Owner's Name. -� s --------- ------------------- Phone- d Address------- r ' ------------•-------------------------------------------------------------------------------------•----- ------------- Contractor's Name------ ---- •-------- ------^•--------------------7--------------------------- -- -•--- Phone___/._ %___f�_ � Installation will serve: Residence Apartment House ❑. Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _:_1_._>M N ber of bedrooms Number of baths __.C__- Lot size _________________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table Q ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam E] Clay L m E] Clay E] Adobe Hardpan ❑ Previous Application Made: Yes E] No [. New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: �' �.�c. ,•ur. (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 0, " Septic Tank: Distance from nearest well-----------------Distance from foundation________-_---_--.Material_____.________.__..__--_---_--__---_________.._. El6 No. of compartments-- ----- -----------Size---------------------------- ---Liquid depth-------------- -----------Capacity--------------- -------rrrv.`` Disposal Fie Distance from nearest well__---------------Distance from foundation--------------------Distance to nearest lot line________-_------.W ❑ Number of lines-----------------------------------Length of each line------------------------------Width of french------------------------------_Or ._-- Type of filter material________________ Depth of filter material------------------- length--------------------------------------i_-- Seepa Pit: Distance to nearest well_. --Distance fjfyj foun ation______v5_�____--Distance to nearest lot lin --�0------ [✓ Number of pits_______ ____________Lining material__G_�*_ Size: Diameter_____JJ-u------Depth--------Q -,----------_- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- �1 ❑ Size: Diameter--------------------- ----------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well___________________________________._._____.._._Distance from nearest building____.-.._------_______________.______..__. ❑ Distance to nearest lot-line------------------------------------------------- - Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------•--------------------------------..__.._... --------------------------------------------- --•------------•----------------- •-------------------------------------------------•-------------------------------------------------------------------------------------- ------------------------------------------ ----------------------------------------•----•------•------------------------------------------------------------------------------------------------------------------------ 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)----------60 YCl--------- ---------------------------------------------------------------------- ---------- r 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--- --------------------------- DAT -.�----------------------------------------- REVIEWEDBY------------------------------- - -------------------------------------------------------------------------------.--- DATE__ --------------------------- •--------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------------------- --------------------------- DATE------ Alterations and/or recommendations--------------- --------------------------------------------------------------------•------------------------•-•-------------...----•-------•------•----------- --------------------------------------------------------------------------------------------------------------------------------------------------•----•---------•----_-•--------------------------------------•------------- ---------------------------------•-------------------•---------•------•---------------------------------- ------- --------- ------ -----------•-----•-------------------------------------•------------------------------•---- --------------------------------- -- ------ ------------- -------------------- --------------------------------•----•- --------------•----------------------------------------------------------------------------•---------- FINAL INSPECTION BY:------------ ..— -•- .-----t------------------------ 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 10-52 Revised W-2100