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r. !� APPLICATION FOR SANITATION PERMIT Permit No. (Complefe in Duplicate) _ Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work This application is made in compliance with County Ordinanc o. 549. � ) 3 � JOB ADDRESS-AND L CATION_. ___-____-- 9 -- ?�r Owner's Nance' -•---- � . r - --- Address _e -, ¢_ ----_Contractor's-Name-------------- 4 � .-- --------------------------------------------------------------- --- -•--- -- ----------- ------------ ------------� ------- ------------ -�-------- --------------------------------- Phone-Installation will serve: Residence Apartment House ❑ ❑ Trailer'Court ❑ Motel ' otel ElOther ❑ 14 Number of living ,�units -__._ Number of bedrooms -- Number of baths -_f-- Lot size Q _______________ ___ Wafer Supply: Public system Community system Y y ❑ Private [] Depth to Water Table��ft. Character of soil.to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado Hardpan ❑ Previous Appl cafion Made: �Yesx fNo ❑ -New Construction: Ye No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r , (No septic tank or cesspool permitted if public sewer is available within 200 feet.) "~ - Septic Tankk:#\.'^` ''bstance from nearest wel rY t ; P__Distance from fo ndation/a-------____.Material __ __ No of com artments j - --------- -- - , P �_ --- Size_ X--��-X�-----Liquid depth_ T3 Capacit _}� --- v5 Disposal Field: bistance from nearest weilrr- pistance from foundafion/ -'_:__:'Distance to nearest lot line____�1_�_• Number of lines______!_______ _____ ____ _____Length of each line_______ 49 ______-- Width of trench----- Type of filter materia ------- ---------- --- Yp . __ __ _____ Depth of filter material-- - ---_____-Total length_--`_.__�'4�_-_--_ `^ Seepage Pit: Distance to nearest well Distance fr m fo .dation--le-1Z•�_ � v? ___..Distance to nearest lot €ine-'- Number of pits---_---- _________ fining material Size. Diameter______. __� �r '� ------Deptn_:_.--- Cesspool: Distance from nearest well _Distance from foundation__-_--________---_-Lining material-__.__-_-_______-________---_ ❑ Size: Diameter------�------------� - M r ------.. Depth ---------------------Liquid Capacity gals. rivy: DIst ce from nearest well____--_---_ -__ ________ Distance from nearesr building-_......__---•--_� , -------- ❑ Distance to nearest lot line________________ _ ----------- -- ____ _____ --� Remodeling and/or repairing (describe)_________________T Y ------•------ ---- i -------•-------- •-------------- ------------------------------- ------------------ I hereby certify that I have prepared this pplicafion and that the work wi!kbe done in accordance with San Joaquin County ordinances, State laws, rules an egulat' 'n f the San J aquin ocal H al h District. (Signed)----------- 1 --_ -:_.-__(Owner and/or Contractor) (Plot plan, s wing size of lot, location of system in relation to wells, buildings, --- ------;--XIn efc.. can be placed on revee side)I • r.....- v FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY_ --------------------------- ---------- -------�-- ------------- ------------•---------- -- DATE, _. --- REVIEWED BY------ ----- ---- -- DATE----- BUILDING PERMIT ISSUED_____ - -------------------------------------------------------•-------------------- Alterafions and/or recommendations:-_- DATE_______________ I N. ------------------ ----------•------------ ----- ---- FINAL INSPECTION BY: -- ---- -- Date �5�_.3 --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C":S+rest Stoekton; California Lodi, California Manteca, California Tragy, CaliFornia ES-9-2M 10-52 Revised'W-2100