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APPLICATION FOR SANITATION PERMIT Permit o. �I5 (Complete in Duplicate) _ Date Issued A licat-son is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. pp Y This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION--------- - ---Vg ---•--------------------------------------- Owner's Name--------------------------------- "E� �` i__C7--mss-----------� . Phone ` Address----------------------------------------------------ti-L---WW'---15M-----�� ,/-------------------------------------------------------....----------------------------------------------- Contractor's Name----------------------------- ----�t-_. Q r! 3f Phone -�� 7-- t Installation will serve: Residence fK Apartment House ❑ Commercial ❑ Tr iter Court I-] Motel El Other I-]Number of living units: J--- Number of bedrooms ,Z_- Number of baths-- Lot size ------ _�._-' ___._ _ --- r Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table .a- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoK New Construction: YesM No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.] Septic Tank: Distance from nearest well _I --Distance fro fundationa Material No. of compartments-----�------------ --- Liquid `.----------Capauty�s4wff- Disposal Field: Distance from nearest well_A07U-7--.Distance from foundation__f4?------------Distance to nearest lot line-AS-------- -- k Number of lines-------J---------- p' Length of each line__--_ --- -------__.-__.Width of trench-_�-_�''_'------------------- Type of filter material----!-PY-- A--Depth of filter material-----S ....--_--Total length------- ---____- l Seepage Pit: Distance to nearest w�_��_�fm'�-�-''.--�Qteraalce fr f��dSize:nD a�er�Distance toDnep��st��e__a�.f_____ Number of its-----_---- Cesspool: Distance from nearest well-----------------Distance from foundation--------_----------.Lining material__-____-____-----_-----_----__-_-__--. ❑ Size: Diameter--------------------------------------Depth---------------------------•------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well 4 -_. 4 Distance from nearest building--_---_-______-:-_.-.--- . F1Distance to nearest lot iine------------------ ------ ----------------------------------------•-----•--•------- ---------------------------------•--•-------------------- Remodeling and/or repairing (describe):------ ---'-----------------------------------------------•---------- .............----------------------------------------------------------•----------------------------------••------------------------------------------------------------------------------------------------------------ ----------------------•--------------------- -------------•------------------------------------------------------------------------------------------------------------------------------•---------------------------- ------------------------------------------------------------•-------------------------------------------- ----------------------------------------------------------•-•--------------------- ------ (� I hereby certify that I haveprepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rulaa regulations of the an Joaquin Local Health District. --- (Signed)----- -9-- ------ s.,\ - -- -------- -- ------ E Contractor) ..... �- ----��--------I--- ---------- -------------------------------------------------------------------------(Title) `-- --� �------------- (Plot plan, ing size of lot, location of stem in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ---------------------------------------------------------------- DATE--. ----- ------ --------------------- REVIEWED BY---------------------------------- ---------------------- ------------------------------------------------------- DATE_----------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------r''---------------------------------------------- Alterationsand/or recommendations---------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- i FINAL INSPECTION BY----------- --------- ---------- Date-------------F .- ----- ------- r i SAN JOAQUIN LOCAL HEALTH DISTRICT I 130 South American Street 300 West Oak Streef 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M 8-51 Revised W-2100