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r APPLICATION FOR SANITATION PERMIT Permit No. _". _S_a- (Complete in Duplicate) .,. Date Issued ._-�"��.?�,5�� This a a{ion is hereby made to the San Joaquin Local Health District for a permit to Construcfi and install the work herein described. This application is made in compliance with County Ordinance No. 549. ' ed. JOB ADDRESS AND LOCATI `� T t _ Owner's Name----------------•----------- •---------- " etsr- � ---•-------- ------------------ Address ------•-------------------------- -------- Phonej9___4/ - ----4/ Contractor's Name- ------------------------------••-------------------------•------------ --- _------"- Installation will serve: Residence ---------- Phone---1 _--_6,f 0 ------------------------------------------------House ❑ Commercial ❑ Trailer Court [] Mote! Number of living units: _I--_ Number of bedrooms _"4/ ❑ Other [] Wafer Supply: Public system / Number of baths "�--_- Lot size ----- ------------------------------------------- � – L!� Communit system •--- --- --------- 4 Y Y ❑ Private ❑ Depth to Water Table SV ft. Character of soil +o a depth of 3 feet: Sand � ❑ Gravel ❑ Sandy Loam ❑ Cla Loam ,�/� Previous Application Made: Yes El No Y ❑ Clay ❑ Adobe L� Hardpan [j TYPE OF INSTALLATION AND SPECIFICATIONS:New Construction: Yes E] No [] (No septic tank or cesspool permitted if Public sewer is available within n 200 feet.) S ti T nk,: Distance from nearest well-----------------Distance from foundation""_""-__.___ No. of compartments------------------ --.Material_ -------------------------------- Size Liquid depth Capacity Q• sal Fisl r 1?istance from nearest well-----------------Distance from foundation_"_ _.Distance to nearest lot Gne-""_____________ `r Number of lines-----------------------------------Length of each line-_"-"" Type of filter material----" -- .........Width of trench----------------------------------- t Depth of filter material---------------- -"----Total length"_-""_"--______ """-- Seepage ti � Distance to nearest well- -- 1 Distance om fqundation_- r-- 1�'umber of pits_" p------.Disfiance to nearest lot line-_---�_,-_! Lining material---------------"-[--.Size: Diameter- `+ -- Cess ---------------- Cesspool: } ----------Depth- f" Q ❑p Distance from nearest well-___'-___- __Distance from foundation-_---------------- Lining material_- ""---_-___-__ � Q l Size: Diameter------------------ --------------Depth--------- ------ ---------------- ---------Liquid Capacity----------------------------Distance from nearest well_--. _gals. fv a - . ".."Distance from nearest buildin ❑ Distance to nearest lot Gne g ----------"__-"-_""__ ll emodeling and/or repairing:(describe):_.._"----. ------------------------------------------------------- Ihereby certify hat have prepared this pplication and that the work will be done in accordance with San Joaquin County ordinances, State d rules and egulati s of the San Joaquin Local Health District. (Signed)-------------------- - BY:------ Re Contractor) (rtleJ (Plot plan, showing size of lot, location of system in relation tow 1 , ---- buildings, e+c. ca be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY REVIEWED BY DATE- _" BUILDING PERMIT ISSU= - ----------- DATE - _-_------- -------------- -- - _____ --------- -- ---------------•- erations and/or recommendations:---------- DATE ------------------- ----- --- ---- ------------ ---- -------------- ----------------------------- ---------------------------------------------- FINAL INSPECTION BY:- r ------ --------------------- Date----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Street 300 West Oak Street Stockton, Celifornie 132 Sycamore Street •814 North "C" Street 4 Lodi, California Manteca, California Treey, California ES-9-2M Revised W-2100