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S APPLICATION FOR SANITATION PERMIT Permit Na. (Complete in Duplicate) .Date issued ---�� "� install the k herein escribed. Application is hereby made #o t e an J'oaguin Local Health District for a permit to const and � This application is made in compliance with County Ordinance No. 549.ed- I c ----- --------------------------- JOB ADDRESS AND L AT10N__._4- - "`' /� ,f� Phone--------------------•-----------•--- 4 Owners Name------------- '!^-� f -------•-------------------------•- { --- f __w- ------- Ad&ess-----------•--------------••----- ' - ---- -------- ----- ------ Phone----------------------------------- - Contractor's Name----------•------------•--------• --------------------o - Other ❑ Installation will serve: Residence ❑ Apartment House ❑ Commercial ® railer Court ❑ Motel ❑ { ---------------- w Number of living units: -------- Number of bedrooms111 -------- Number of baths __._.___ Lot size _____.�__-______-_- )Wafer Supply: Public system 171 Community system E] Private Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel F1 Sandy Loam X Clay Loam ❑ Clay E] Adobe ❑ Hardpan El Made: es No ® New Construction: Yes 5Q No El , Previous Application MdY ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public ewer is avails le within 200 feet.) Distance rom foundation__- 7.----.-.----Material__-- .`-`-Q ---- ► _____-Ca acitp Septic Tank: Distance from nee fest wel!___ __` ____-- s �e Liquid depth p Y No. of comparfinents-------�---------- Size G p ® -�--________.Distance to nearest lotline --------------- ---------._Distance from foundation____-_ Rs' Disposal Field: Distance from nearest well_.-.- Len th of each-line___-_. -- Q----=�--- -.Width of french.-----�-----y--=------- ---• � Number of lines g _Total length------------jam-�----- ------ a � r Type of filter material__ ---- ---Depth of filter material----_ - -.- 1 Seepage Pit: Distance to nearest well------- Lining mteal Distance from foundszienpiameter_-- Distance toDnep nearest ;of ins_-.-^--_-_---' ! ❑ Number of pits_ _ _ _ Distance from nearest well----------------- from foundation___________________ Lining material_____.____________------------------ Cesspool' --- ---_gals. 0� Cesspool: --Liquid Capacity --- ----Depth------------------------------------------------- G p Y ❑ Size: Diameter--- ------------- ---------- Distance from nearest well-------------------------------------------------Distance from nearest building-------------------------------- -------- Privy: ----- . -------- ❑ Distance to nearest lot line.- ----------------------------------- ------- ---------------------- ---- -- - ------------------------ . 9' - cribe}: _4A.je_e_. e ---•------ a --�---------------------------------------------------------------------- - -------- and ----- -- ------- ------ ------ -- - ---- -- ----- ---- -- - • . - that wo rk k I hereby certify t anldh have are aced this a of tation he San Joaquin"Local HealtheDistrictn accordance with San Joaquin County ordinances, State law , ------------------------- (Owner and/or Contractor] g } -[Title} ------------------------------------------------------- BY---------------------------------- -- -- ----P [Plot plan, showing size of. lot, lots on of syem in relation to wells, buildings, etc., can be placed on reverse side]. FOR EP, ,HENT YSE ONLY / '- ------• ----- ---------- ATE-------- --�.�- ---�--- --------------------- ------- --- APPLICATION ACCEPTED BY--------- - ------/-- -- --- -- { DATE REVIEWED BY--- --------------•------------------ -------• --------- ---=---------------------- BUILDING PERMIT ISSUED------------------ ----- --------•------ ------------- DATE.---------- ----------- ------•----------- ---------•------- ------------------------------------- A1+erations and/or recommendations:------- -------- ------- -----••--------•-----•-----•-------_--- ------------------------------------------- -------------- ------------ --------------- ------------------------/--------------- ------- Date__.-------�--- ------------------ FINAL INSPECTION BY:----------- f�Y ------ --------- / SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" $tree+ 130 South American'Street 300 West Oak Street Tracy, California Stockton, California Lodi, California Manteca, California cc_ a_9*,1 io-99 Revised W-2100