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' APPLICATION FOR SANITATION PERMIT Permit No. 1 1 (Complete in Duplicate) p { Date Issued ____--__ Application is hereby made to the San Joaquin Local Health District for a p mit to construct and install the work herein described. This application is made in coin iae with County Ordinance o. 549 7_ JOB ADDRESS AND LOCA T ON__ �s Owner's Name___ Ph Q� ------- one Address-----------------•-- --- ----- ----------------------------------------------------------------- ---------------------------------- ----------- Contractor's Name_____________ ___ _ Phone---7__ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: -- Number of bedrooms _o;� Number of baths =T4 Lot size - Water Supply: Public system Community system '❑ Private ❑ Depth to Wafer Table ________ ff.. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ NoW New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permiffed if pubic sewer is available within 200 feet.) Septic Tank: Distance from nearest wel�' _____-_---__Distance r ro foundation---__ __________Mat�rial_ . No. of com artments____ / __, Liquid dep#h_- _._' " .f-Capacity__ , ' � P ---------- ---Size-- Disposal Field: Distance from nearest well—— Distance from foundation__._.-------Distance to nearest lot fine____ _ 41 Number of lines__________ ___ _ Length of each line__-___ J / ' • g ��--r- ---------------Width of trench--- �------------------------- Type - ----------- � of filter material Depth of filter material___l__ q_ Total length______,9`Q_---___ Seepage Pit: Distance to nearest wel�Ao--------Distance fr .m found tion------ ---------.Distance to:nearest lot line__-_Nall . Number of pits-------- material i p fR- 1.6qp g Size: Diameter__._ Cesspool: Distance from nearest well-----------------Distance from foundation---.----------------Lining material Size: Diameter----- -------------------------------Depth---------------------------------- -----------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____-__-_--____________.________ ------ ♦" ❑ Distance to nearest lot line_________ - Remodeling and/or repairing (describe)_____________ ___ ___ ° ---------•------------------------------------------- -•---•-------------------------- -------------------------------------------- ---- ------ ------ ----- ----- - ----- -- --- - - -- ---------------- ----- ------ -- ------ I hereby certify that I have prepared this application and fhat the work will be done in accordance wifh San Joaquin Counfy ordinances, Statews, and rule and regulations of the San Joaquin Local Health District. (Signed)------------ -----:: ____{Owner and/or Contractor] �y:----•------- - i ---A----------- -- -------(Title)-- 4 _ (Plof plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side. ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___________________________ -------------------------------------------------------- REVIE WED BY--------------------------------- -------- DATE--- 0'4-- ---------------------------------------------- BUILDING PERMIT ISSUED__---_____-- __--- DATE--------�----------------- ----- - -------------------------------------------------------------- -------------------- ------------------------ Alterations and/or recommendations:-__, -------------------------_------------------------------------------------------------------------- ------------------------------------------------------------ - ---------------------------------- ------------------------ -------------------------------------------------------------------- -----------------------------------------"---------- i ------------•----- FINAL INSPECTION BY:--. Date-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oafs Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California k ES-9-2M 8-51 Revised W-2100