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APPLICATION ATION FOR SANITATION PERMIT Permit No. .__ "-1-- {Complete in Duplicate} Date Issued ---�- . Application is hereby made to the San'Joaquin Local Health District for a permit to construct and install the work herein described. This ap glicafionfis..madeJn-compliance'with County. Ordinance No. 549. r Ir � r� moi, .-� 1-r-A- JOB ADDRESS ND`LOCATIO - ----- ---- ----- - --- l. -------------- Phone -----------------•--- Owner s Na a-----._ r - f _ .-------------------•----------------=--- Address...----_�-- = ` ' I Phone----------------------------- Contractor's Name----------•-------------- ---------------------------------------------------------- ----------------------- -- Installation will serve: 1} Residence Apartment House Commercial ❑ Trailer Court ❑( [rM(x/fojel [I Other Other ❑ / 1 1.� 5-- ----------------------•_ Number of living units: ---1--- Number of bedrooms -- Number f baths •_.d-_-- Lot size -_--F--..____.____ i Private e th to Water Table -------- ft. 1 Water Supply: Public system ❑ Community syst ❑ P Character of soil to a'depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes F1 No ❑ New Construction. -Yes E1 No E] F}iA/VA: Yes ❑ No E] I TYPE OF INSTALLAT21ON AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet Septic Tank: Distance from newest well_ -LC- ista ce from fou da ! - ater al-------_.-:---- ----------=-- -- Se - of compartments----------- -----1---- S'. -�- _ -- squid depth . .-Capacity---------- Nb!. ";'14 *> I istance from foundation-eO-_I�"'--.Uis#ante to nearest lot li .ef---_. --•- - Dispos Field: Distance from nearest w I ___-. Number of lines___________ ___ Length of each line_--_----_------- - _Width of trenc ----------- ____------ ---____-- ----- ------ p T e of filter maters - e th of filter material- --- - ---------Total length-------------- ___-- YP -- a-� Seepage Pit: Distance to nearest well _---_---_-_ :-Distance from foundation--------------------Distance to nearest 4ot line--.--_.----___-- ❑ Number of pits---------------- ----Lining material---------------------- Size: Diameter----•-____._-----------Depth--- --------- - Cesspool: Distance from nearest well-----------------Distance from foundation--------------.----.Lining material------------------ ------ ----- al-- !1i ! ❑ Size: Diameter------------------------- ------------Depth----------------------------------------------------Liquid Capacity----------------------------g Privy: Distance from nearest well------------------------------------ ---Distance from nearest building------------------------------ ------ ❑ ------------------------ ------------ Distance to nearest lot line--- ---- ----------- -- -----------------•------------------------ ------ Rodg nd/or r pairs de c ibe�:--- ------------------------ - t - - ---------- -- 2i9= = ------------------------------------ �-----------------------------------------------------------•----------_..•- 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. f �'� --------------------------- - [Owner and/or Contractor [Signed)- } By:---- -•--------------------------------------------------------------------------------------------------------------------------[Titl } e (Plot plan, showing size of lot, location"of system in relation to wells, buildings, etc., can be placed on reverse side). vim ` FOR DEPARTMENT USE ONLY ------------------ APPLICATION ACCEPTED BY- - ------------------------------------------------•------------- DATE------------------------ BUILD NG PERMIT ISSUED--------- ---------------- --------------------------- :---------------- - DATE_--� - ---- Alterations and/or recommendations-------------------------- •--------------••-_----------- -----•--------------------------------------- -- -----------------------------------•--------------------------------------- -- FINAL .INSPECTION BY:.--------- �' ,. -------------- Date , -- SAN JOAQUIN LOCAL HEALTH DISTRICT 1 i30 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 Revisea 1-57 F.P.CO.