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APPLICATION FOR SANITATION PERMIT Permit No. (Complete'in\Duplicate) Data Issued -_--3-- ��-- Ii 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 in compliance with County�Ordinance No. 549.. ------------------------------- ' JOB ADDRESS AND LOCATION: 7 ..4-------------------------------------------------------- Phone_ 9f'4 Owner's Name__ ___ - ----------- - ---- ` '� = P �. . L Address------�1�-�f�------�--n'-------- -- ---- --- -�- ------------ Contractor's NameY_ r r----------------------------- Phone. f ' Installation will serve: Residence ID Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units: _1---- Number of bedrooms _�__ Number of baths ---J-- Lot size _____C ---------------- Water - -------------Water Supply: Public system ®' Commuriity system ❑ Private ❑ Depth to Water Table 3Q ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy loam ❑ Clay Loam ❑ Clay ❑ Adobe, ] Hardpan ❑ CW Previous Application Made: Yes E] No'M New Construction: Yes ❑ No FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is.available within 200 feet.) ,Septic ank: Distance from nearest well------------------Distance from foundation--------------------Material ______________._______.____________-__________.. ` No. of compartments-------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- �. Dispos field: Distance from nearest well_ _._.____.;_.Distance from foundation--------------------Distanca to nearest lot line----------------- f Number of lines____________________1 \-------NLength of each line-----------------------------Width of trench----------------------------------- r ' Type of filter material-_---------------------Depth of filter material-- -------:---------•--Total length----------------------------------------- { i I Seepage it: Distance to nearest well_-_.�0��____-.-Distance from fo dation-_______.___.Distance to nearest lot line--&S__.____._ \ Number of pits--------J----------Lining material__- --size: Diamete r--��y7�j-!------.Depth---- �? ---------- ----- --material ---- o Cesspool: Distance from-nearest.we!!.___.___ Distance.from,foundation________._,__.___-Lining"mater+al____________________________________. ❑ Size: Diameter---- ---------------------- Depth----------------------------r =-------------- Liquid Capacity gals. Priv Distance from nearest well- ---------------------------------------_-- Distance from nearest buifding ------------ Privy!.y: - c + --- -- -- ---------------------------------------------------------- ❑ Distance to nearest lot_ line.1----------------v---------------------------------------------- «.; s / /' ' Remodeling and/or repairing (descrsbef:------- I i -----•-------•---------------•----•---------------------------------4 --------------------- ------------------------------------------ ------------ - I -----------' �n----------------------------------------- ------------------------------------------------\_----------------------------------------------- --------- ---- 1 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 regulationsofthe San oaquin Local Health District. + a' (Signed)---t 46� : ------ - --•- -" -------- - (Own and/or Contractor) e t i .e ' -- ---------.._.. { g -.e _,S!, ---------------------------------------------------(Titl �Z 'rs -- y- e) Plot Ian �showin size of lot, location iof system in relation to wells, buildings, etc., can be placed on reverse side. ( p �€ g ; \ FOR DEPARTMENT USE ONLY q APPLI GATE--- -z '— ----------- CATION'ACCEPTED BY- (JW-c+r ---------------- REVIEWEDBY------------------------------------------'-------------------------------------------------- • DATE tBUILDING PERMIT ISSUED------------------ {-----------------------�S------------------------------------------------------- DATE-----------•----------------•---------- --- ------------- Alterations and/or recommendations:---i---=------------------ J- ----------------- --- ------- ----------- ----------------------- --------------•-------------------------------------------..---------- -- - ------ - ----- FINAL INSPECTION' BY:. . ----- Date- ------ ~ID SAN JOAQUIN LOCAL HE LTH DISTRICT 130 South American Street..__ ,,,300 West Oak Stree} 132 Sycamore Street 814 North "C" St Stockton, California I Lodi, California Manteca. California Tracy, California E ES-9-2M Revised 1.57 ir.P.CO.