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APPLICATION FOR SANITATION PERMIT Permit No. -------------- (Complete in Duplicate) Date Issued`_--..- l�� 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 County Ordinance No. 54 JOB ADDRESS A LOCATION. 1.�v-_______ 3__�_ �,/ ----- ----------- ---------------------------------------•----------------------------------- Owner's Name------- --- -• ------_&- ----- Phone Address---------- ,. 5,--------- Contractor's Name �!4_ Phondyl' -41'o_(2(- Installation will serve: Residence @4--7\partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1--- Number of bedrooms -A. Number of baths ---/-- Lot size ____,_,_49-R ___ Water Supply: Public system E] Community system E] Private ��pth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe�ardpan ❑ Previous Application Made: Yes ❑ No 29--,New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Distance from nearest well---"- Distance from foundation-----JP!' Material_--.----_-__----- ------ ------- ---------- No. of compartments----------- „... ..... Size.- --- -- - -_Li uid de th_--- L 1 q P. 49�-----------Capacity-•-- Disposal Field: Distance from nearest we€f.___,TQ....Distance from foundation___.3_ 0-_1---.Distance to nearest lot lin e_-- "- ...... Number of lines------------------/--------------Length of each line----------- ' g ��'- _.-_.-.Width of trench.-(23'r-3, -- Type of filter material__ .: De th �' ------------------ A of filter material Total length 3� Seeps e Pit: Distance to nearest well-.---- - Distance from fo ndation------ 8_�_.Distance to nearest lo.t�ine% Number of pits------- ------------Lining material---J�iasrz , ____.--.Size: Diameter----. --'5K-........Depth-.. - - -------------- 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 that the work will be done in accordance with San Joaquin County ordinances, StPaws' and rules d regulations of the San Joaquin Local Health District. (Signed)---------- -•- --- -----------•---• . --------- ---------• -------- - Ar��1.�.- Contractor) 8Y� ..c ' - •--------------------------- - " - ------ ----------(Title)..- -- - - ------------------------- at plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r f APPLICATION ACCEPTED BY-------------------------------------- -------------------- DATE r REVIEWED BY -. ----------- ------- ----------------- -----------------------------------•-. DATE----- ---•------ -••--••------------BUILDING PERMIT ISSUED --------------------- -------------- ------------------•-- DATE.-----------------------------------•- ' Alterations and/or recommendations---------------------- I ------------------- -•--•-------------- ------------------------------------ j----------------------------------------- ----------•--••-------•-------•---------G� .�.---------------------- -----FINAL INSPECTION BY----------------- } •------ Date------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Streot 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 3