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I APPLICATION FOR SANITATION PERMIT Permit No ---_G (Complete in Duplicate) Date Issued Applica4,ion 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 LOCA ON___-- - - ___ . - ------ /U� '✓� + -• Owner's Name____.___-__ _ •"�-_- -_� ---------------------------- . ` - -- -- - -- --- - ------------ --------- ---------- ------- - Phone Address--------A-- ...( -.. --"-Y-- - _ - -"-- - _ Contractor's Name_____f __.._ __ /•d - - -- f--------•-----------=-------- - Phone_ � �f/�t�� Installation will serve: !Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Water Sup ply:lof g units: �_.�__ Number of bedrooms _- _- Number of baths .__�___ Lot size _____ _"-X-_--/,op - - pp y Publicsystem'�[ Community system ❑ 'Private ❑ Depth to Wafter Tabled ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay'Loam ❑ Clay ❑ Adobe Hardpan E]i Previous Application Made: Yes E] No,-_ New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septirs tank or cesspool permitted if public sewer is available within 200 feet.) W' Septic Tan'( from nearest well-----------------Distance from foundation -Material------------------------------------------------ ❑ No compartments Size i---------Liquid depth--------------------------Capacity_ -------------------- Disposal Fiel nearest well________________cDistance from foundation----.___.___.__---.Distance to nearest lot line.______.-____.___ ❑ Number Ines- ------------------------------Length of each line------------------------------Width of french Type or filter material-------------------------Depth of filter material------------------If----Total length----.------------------------------ _ - ... Seepage Pit: Distance to nearest well_._,f �Distance from fourid tion___- _��______--Dis}ancj'to nearest lot lin ��"- Number of its.-_. �--- -- P Lining material_ °tel e: Diameter------,,,' ?-------Depth------4" 1 t ----------------- Cesspool: Distance from nearest well-----------------Distance from foundation--___._____,_______.Lining material_ _-_______-__-_ -_- DO DO --- 11 Size: Diameter--------------------------------------- ----- ----------•- ------------ -Depth---------------------------------------------------Liquid Capacity------ -------------------gals. 4fi Privy:' Distance from nearest well"_ ______________---------------❑ Distance from nearest building Distance to nearest lot-line _�__-_..._____-_.._ ------------------------------------ Remodeling and/or repairing (describe)___________________________ ______ _- "_ - ----------------------------------- ------------------------------_•---------------•----------------------------•- --------------------------------------------------- ------------ I;hereby ce --- -------------- --------------•--------------------------------------------------•--------------- i that I have prepared this application and that the work will be done.in accordance with San Joaquin County ordinances, S e law ,. and rules and regulations of the San Joaquin Local Health Districf'. (Signed)------ ------ --- -- ------- __ .___-Owner and/or Contractor) BY= f --- - - --'�- _(Title)___ i _ _ _ _ _ - _ Lai___________________________ ___ _ ___.[__.-______._____-_._ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side-- 7 i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- ------ ""--, ~ DATE '-0--------- IEWEDBY- = ------------------------------- --- ----- •- ------------------------- DATE ---------- BUILDING PERMIT ISSUED--------------------------------------- �--�- - --------- � �-------------------------- ----------------- -------•-------------••------------•-- DATE---------- -� Alterations and/or recommendations_________________________ _ __ -- -•-------------------------••--------------•- ---------------- q---- --------�Z------- --- ------------- ------- -- --------- --------------------------------------------------------------------------------------------------------------------- \_j -------------•---------- -------------•------------ --- --- ------------ - --------------------------- FINAL INSPECTION BY:- --------------- = == Date---,. d- %47 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California H-9—' 2M Revised W-2100