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APPLICATION FOR -SANITATION PERMIT Permit No. ._IO2_ (Complete in Duplicate) –� ' I Date Issued 1 Application is hereby made to the San Joaquin Lo 'c Health District for a permit to construct and install the work herei described. This application is made,•in.complian_e Yith County Ordinance No. 549. JOB ADDRESS AN LOCATION4e r � t .. Owner's Name --------------•- P ne ------------------------------------ -------------- ------------------------------- Address ..•------- Contractor's Name------- - ---------- -- ----• •----------------- --- Phone-------------------- Installation will serve: Residence I Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other .�'.. Number of living units: -------- Number of bedrooms ------_ Number of baths -------- Lot size ---�_.Q ry ------------------- -- :L Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table -A--, _ ft. Character of soil to a depth of 3 fees: Sand ❑ Gravel [ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ .No'�J New Constrru`ction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: S (No septic tank or cesspool permitted if.public sewerVIVIV ariable within 200 feet.) SepticxTa '• �-.� istance from nearest we4_3b'V__. from foundation................... M-aterial__--._-- .-_.__---..___--_.. p� No. of compar ---- Size. ---._Liquid depth---------------- --------Capacity----------------------- gS rest well _ 4.Distance from foundationr-�..___ ;Qee is asal Field: Distance from neajQ..__._.Distance to nearest lot li e..--. Number or lines-.-.L-----.-- Length of each line.-.__1__[Sl.c�.E. ..___. idth of trench._ �'�___ > a -- .,.�.--------- of filter ma rial.___ Depth of filter-material Z. dI length__-_-./_V,6-- ---------------- Type �. f. Seepage Pit: Distance to nearest well------------------.---Distance from foundation__-__-____-_------.Distance to nearest lot line___ r_1 Number of pits.---t---------- ------Lining material-----------------------Size: Diameter-----------------------Depth---- - ----------------------------- -------- -______________ ----- Cesspool: Distance from nearest well----------------- from foundation____________________Lining material_-.__...__-__.......,____.._.___.__� ❑ Size: Diameter----- ------ - --- ` ----- Depth -- ----- --- Liquid Capacity'.,,.--.------- - --gals. v Distance from nearest well- _-. -- y' --------.............. ........Distance from nearest building _.....____..._ Distance to nearest lot line ------------- .......................... . Remodeling and/or rep firing [ scribe):__ 'q- _-_____-__••_ A_&�A ------------------ - . ----------•---- -------------------------- ----- -----------------------------------------------••--------------------------------------------------------------------------------•---------------------------------------------------------------------- ............ 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. _ I (Signed]..--- ---------- --- -------------(Owner and/or Contractor) ---- ------ -,. . ---------------------------------------------------------- ----------- By: N(7itle -.; { . (Plot plan, sf�owing size of t; location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------- --•---------------------------- DATE REVIEWED BY _ DATE_ g �� .� �/ ------------------- 1 D1N P1=RM1T ISSUER ------- ------------------- DATE.--- --•----------------- -----A------------l----t----e--------r----a---- terations and/or recommendations:..__._... .--._ --------------------------------------------------------------- - ------------•----------------------- FINAL INSPECTION BY:. '------. -- ---- --------------- Date- . � 9 SAN JOAQUIN LOCAL HEALTH DISTRICT a 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 I0-52 Revised W-2100