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IF APPLICATION FOR SANITATION PERMIT Permit No. --- - ----------- /+� [Complete in Duplicate) \ Date Issued --- ;� '�-- - 4 pplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. its application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION ---------- -------- -- ------------ �_.t ----- -----------------------_ -------------------- ------ Phone-- ,�'~ C Owner's Name----• ----•---- ------------- - Address-•-- AMI-e- ----- . /� ------------------------------•-------...- Contractor's Name------ +2X . --•-- ----- ----------------- ------------ --- -•----------------------- Phone/ - ' Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ L� Number of livin units: --- Number of bedrooms 9 Number of baths - Lot size - �------------------------------ Water Supply: Public system '"Com`muni+y'system ❑ Private ❑ Depth to Water Table 4 Character of soil to a depth of 3 fee+c`Sad ❑`Gravel E] . Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No tM New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: � ' } (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Disfance from foundation--------------------Material_..---- ------------------------------.--------- F_�f `i*vf No. of compartments--------------------------Size------------------- ----------Liquid depth--------------------- Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- 1 [ Number oilines-----------•-----------------------Length of each line---------------------.--------Width of trench--------------,-------------------- if t � Type of filter material-._--_.---- p g Depth of fit}er material-----------------------Total len th-_ � � s1 Seepage Pit: Distance to nearest jei---JI/D,v-e----Distance f:from foundation----I9-F.........Distance to nearest lot line-4r./ -_--- j ® Number of pits- Lining material--•-�Q&t. --,-Size: Diameter---��!------ --Depth---�-. �----- \ esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material -.--------.__----------------------- p� ( ❑ Size: Diameter-------- -----------------------------Depth--------------------------------_- .------ ----Liquid Capacity----------------- ----------gals. M 1 j Privy:" Distance from nearest well------------------------------------------------.-Distance from nearest building----------------------.------------------. vJy ❑ ' Distance to nearest lot line---------------- Remodeling and/or repairing (describe):--4_/G �----- r I � - --- = --------------------------------- 1-19c7- y� ^ ' --------------------------------------------=-------------------------------------------------•--------'--------------------------------------------------------------'-.-. ----------.-------------------------------'-----------•------------------------•------------.....-...-.-...---------------------------------------------------------------------------------------------- -------------.- 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) -------- (Owner and/or Contractor) 3 gY� z .- f .. --------------------------------------------------------- (Title)---,.k ----- --- (Pio+ plan, showing siz` 'of lot, loca+ionof.system in relation to wells, buildings, etc., can be placed on reverse side). ! FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- ----------------- --- --- - -------- ------------------------------------------------- DATE---- REVIEWED BY------------------------------------- ----------------------J -- --------------- ------------------------------------------ DATE--' ---- ATE--- --- �- BUILDIN,G� ER ISSUED--------------- }-------------------------- -------------------------------------------------- DATE-------- ` - - ! Alters 'dns /or re o mendations:------------- ----- - - -- - -- ----- ---- - --- --- 01 . - ------ ------- --- - ----------- ---- :_ _= •---------------------------------------------------------------------------- ---- .. t INSPECTION BY--- ---------------•-------------------- --- -- ------------- Date - ----- --- --- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT k` 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 'I