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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Y/ Date Issued Applicata&� 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. 549. JOB ADDRESS AND LOCATIO = - -<!�c.' ---------------------------------------------------------------------- Owner's Name --- ----------------------------------- -------- Phone Address------------------------- --------------- -- ----------------------------------------..------------ Contractor's Name------.----- JrLL - ----------•-------- Phone......H _-�'7�- Installation will serve: Residence Apartment H se ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Lg— - Number of living units: --------- Number of bedrooms ---- Number of baths -------- Lot size ----------6--oxf_s5_O_____________________ Water Supply: Public system 5A- Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Aclobej]�_ # rdpan ❑ Previous Application Made: Yes No ❑ New Construction: YescE]_—No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic nk: Distance from nearest wel!__ ---P1i _Distance`fiom found tion_-_-./-L'-_-------.Maternal___ r L-__--..� No. of compartments....... -------- -Size-------f�_G._-. '-1 1grL --Liquid depth______�q_#0---------Capacity.._&49(_ � Dt - Disposal Field: Distance from nearest well-1�/�1_:{' Distance- from foundation---�_�___._.-_.Distance to nearest lot line______ �"`1............Width of trench.-----�" -- -------------- [� Number of lines_____________ ___________ ________Length of each line----------_._ fr Type or filter material-`j_!.._� __-Depth of filter material-_.._�__ ___________Total length.----_--.�-. ._'________.__________ Seepage Pit: Distance to nearest ell...------ -.-_9)"__-Distances�from f undation___-. lr"_ _____.Dista Distance to to nearest lot line------;."___ Number of pits__----__ ___________Lining material-(.€•Y_,t --_--..Size: Diameter.__-.. $_______Depth_...___ t �---__._-__.. Cesspool: Distance from nearest well______________ Distance from, foundation____----------------Lining material---------------........-------.------- ❑ Size: Diameter- ----------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Q 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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed} � '- ---------- -gwner and/or Contractor) —� - BY ----- ---- ------(Title)--------- - ------- ---------------------- (Plot pian, showing size of lot, location oVsystem in lation to wells, buildings, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- ---------------Y------------------------------------------ DATE--- ------------------------------- ---------- REVIEWED BY------------------------------------- ----------------------- DATE------ ------- or- BUILDINGPERMIT ISSUED------------------------ ------------------------------------------------------- DATE------------- - --- 1'--^----------------------------- Alterations and/or recommendations:---------------------- --- ----------------- ---------------------------------------------------------------�•-�-•------------------------- I� ----------------------- -- ---•------------------------ --------------------- ------ -e� ------- --- ---- ------------ - - - ::. X`c4A-�A --- --------------------------------------- --------------------------------------------- .._ __._.._._-. ------------- FINAL INSPECTION BY:.--------.- -- ---------------------------------- Date..... ----------------------------- --------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT ` 130 South American Street 300 West Oak Street 132 Sycamore Street 814 Norfh "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ' ES-9-2M Revised W-2100