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APPLICATION FOR SANITATION PERMIT Permit No. --------------------o---- " (Complete in Duplicate) Date Issued _-I--l--cAl Ali Applica+ion 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 C unty Ordinance No. 549. 1 .706 ADDRESS AND LOCATION ... lam- -------- -- "^..� ----•---- ---- ----•------ /?"`" Owner's Name--/�-- ---.. --------- Phone---------- . r � , Address_.__.... .�-a------- ------- - - - - - - -- ---- -- ---- - ----------- --------------- Contractor's' Name----�r' " '3r�'---------------------------------------------------------------- ------------ Phone-----....__---.---•------------ Instaliation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer-6e Motel E] Other E]a- Number of living units: _ ___-_ Number of bedrooms -.- Number of baths _1___ Lot size ___I&TO Ne— Water Supply: Public system ❑ Community system [] Private [� Depth to Water Table 4rft. Character of soil to a depth'of 3 feet: ` Sand X Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made:'i Yes [-] No New Construction: Yes al No ❑ u TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel!___:7.a_.___Distan e fr m foundation___-0______.Mat tial_ _______ _______ No. ofcompartments-----�----------------Size--- -5 -, ---_..Lic}uid depth-----_?------- ------_-Capacity__ P _---------------- Disposal Field: Distance from nearest well-4_0-------Distance from foundat' Distance to nearest lot line______!_____-_--_ Number,of;lines_________ ____ ____ f Length of each line_- Y ____ ____________Width of trench--_ �_`----_--------------- Type of;,filter materi _ 04--Depth of filter material____-IcP.............Total length___�,7!__________________________ U E ' Seepage Pit: -Distance'to nearest`well______________________Distance from foundation--------------------Distance- to nearest lot lime___=____________ ❑ Number'of pits--- -- --------------Lining material-----------------------Size: Diameter------------------------Depth____.._________:_-_________-_._ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__._______________________________. ❑ Size: Diameter-------=----------------------------Depth----------------.------------- ------- .-.----Liquid Capacity_--------------------------gals. { Privy: Distance from nearest well_._.________________________________________r.-Distance from nearest building-------------_-__--__-_______ ' ❑ Distante,to nearest lot-line-----------=----- " _ ------ --------------------------------------------------------------_--.-_----------------- Remodeling and/or repairing {describe: - - =--------------------------------------------------------------•------- ------------------•---------------------•-•----- I --•---------------------------------------------------------------------------------- {I I hereb rtl'fyy7na have prepared this app'cation an th t k will be done"in accordance with San Joaquin County ordinan State laws ul n r u f et�aq"ui Lac .Health District. (S' ned)-------:--- ', c. '+° ---------------------------------------------------------(Owner and/or Contractor) --- ---- --- ------- Title------------------------------------------ --------------- (Plot ------•-------------..----•---- ------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). T } ° FOR DEPARTMENT USE ONLY T._ APPLICATION ACCEPTED.BY *' --------------------------------------------------------- 0ATE---9"--(/, 7_40Z-------------------------------- REVIEWEDBY--------------------------------------------------------------------------------- -------------------•-----------•---•------- DATE----------------------------------------------------------- BUILDING ---------------BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------------------------------------------------------------- Alterationsand/or recommendations---------------------------------------------- --------------------------------------------------•----------------•----------------•--------------------- --------------•-----•----------•---------------•----•------. ------------------------------------------------------•-----•-•------•------------------------------•-------------------•-------•-•-•--•----•------------------- ---------- --------------------------------------------------------------------------:------------ ---•------- ------------------------•-------------•-----------------------------------------------•---------•---------- -----------------------•------------------------------------------•----------- -- ---------------------------••----------------------•-------••-----•-------•----------------------•--------------------------•-------- f FINAL-INSPECTION --------------------- 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 Revised W-2100