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� . APPLICATION FOR SANITATION PERMIT Permit No. .-- ----------------- (Complete ---- (Complete in Duplicate) // �S-��'" t Date Issued _-----"--- ----------- Application 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 incompliance with County Ordinance No. 549. /7 c'— 2 dO`ff £.� ' j JOB ADDRESS AND LOCATION_=_ - '�-- _ { ; Owner's Name------- t" 7 --- r� / _ Phone Address------&i e c Contractor's Name--- J, ------------------------------------- ---------- Installation --•--------------------------------- -----Installation will serve: Residence.�f Apartment House ❑ Commercial ❑ Trailer -Court ❑ Motel ❑ Other ❑ Number of living units: -1------ Number of bedrooms -- - Number of. baths 1---_ Lot size -------- --------------------------------------------------------------•- Water Supply: Public system ❑ Community system ❑ Private; "_ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam F] Clay Loam ElClay ❑ Adobe,9 Hardpan E] Previous Application Made: Yes ❑ No ❑ New Construction: -Yes:El No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) G Septic Tank: Distance from nearest weil7 - ----"-Distance from foundation_ � -` -----.Material-----------------`--------------------------- No..of compartments---------------X7------Size- _----- �s-_--Liquid depth-_��-`r Capacity-�' -------------- Disposal � 0 eto. , Field: Distance from nearest well-AR Distance from foundation_--- -- .'-_.Distance to nearest lot line__��,.---� p0 I Number of lines- --_._. ._.-."=-_ ' Length of each line------_-__. - ----.Width of trench.__�%�y��___"_____ _- Type of filter material-,��_" � Depth of filter material----/,S/°'-_-_____-Total length_____, Seepage Pit: Distance to nearest well-/ -4-------Distance from foundation__ -.Distance to nearest lot line---- Number of' -- pits. /--- ------_-Lining mate Fal e!�� __Size: Diamefier_- -- -��-------Depth- -- - -- Cesspool: Distance from nearest well-----------------Distance from foundation ❑ Depth --------------------Lining material--_-.-_------"_--.- ------ Size: Diameter--------•--------- ------- ------- ------------------------ -------------Liquid Capacity----------------------------ga S. Privy: Distance from nearest well----------------- ----- -Distance from nearest building r Distance to nearest lot line-__-- -_--_ _----------------- `----------- Remodeling and/or repa�ng'' (de crit,e)---------------------------- z _-� T ------- ------------------------------- i r---- .----- --•------ --------._ /--------------- --- '--�, ------------- ------------------•------------------ r -•------------------•-------•--------------------------- - ---------------------------------------•-------------------------} I hereby certify t t I have prepared\#his application and that the work will be done in accordance with San'Joaquin County ordinances, State law annddd rules and.regulatione� of the San Joaquin Local Health District. (Signed)-------•------------ -- ....""---------------- ------ `� a � +.., - ----- ---- ------ - .�.= I f (Own and/or Contractor) i BY� ---•--•------•-•------• ----I-••-- (Title) "�.-.-f-. - 1_ (Plot plan, showing size of lot, location of system in relation tow ells, buildings, et , can be placed on reverse side). ^' FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY--- ---- ---- ' DATE ---- --- - ---- -------------------------- REVIEWED BY ------------------------------------ .�1-cl Y-------- ----- ----------- DATE ------------------•------ -------------- SUILDING PERMIT ISSUED------------ ------ ---"• x -- ---------------- •----=------------------------------------- - DATE-----------•---•----- ' Alferations and/or recommendstions:-------------------------- .»----------------------------.---.".------------------ .--------------------------------------------------- ----------------------------------- FINAL INSPECTION BY:.-"-- ----- 41�� --------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 lie