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APPLICATION FOR SANITATION PERMIT Permit No.,zr�---71&. (Complete in Duplicate) Date --------------------- 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 fCATION------1, - / - / r?.7Q_�----- __�.--•-----------------------------------------------------•-•---------- Owner's Name------------ Phone. r Address v--- I / ------�`�---i`----�j2�"1�Q-- f` Contractor's Name-------------------------------- ------------•-------------------•---------- ----------------- Phone------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__._ Number of bedrooms __2--Number of baths 1____ Lot size -------�._3/ _1__f 4_ -------------- r _a Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table -__ ft. V� Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam 0 Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes g?"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well--- -------Distance from foundation_ --.Mat riial�- � /� + • No. of compartments_____-__�Y__.__.___-5ize____E4. f 'Liquid depth------T__-----------_Capacity------- !� f from F blr�� , f Dispos I Field: Distance from nearest well_�._____._Dlstance r found`afson____r;__:._..-_.Distance to nearest lot line____._S_._____ Number of lines________? -------_ -.__._L�ength of each line________------------------Width of trench------------ <<__:_____._ �� ll ------._Total length---------------- Q Type of filter materia_ y ('_ -�Jepth of filter mater---___.__'__fc _ Seepage Pit: Distance to nearest well---------------------Distance from foundation------------------- Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size: Diameter----------------------Depth-_-----.------------------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material____________-------_____._____.______ ❑ Size: Diameter------------------ -------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals . Privy: Distance from nearest well-----------------------------------------------._Distance from nearest building--------_--_--.______________-__-.____._. Distanceto nearest lot line------ -- -------------------------- --------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (described:--- ----- -------------------------------------------------------------------------------------- -------------------------------------------------------- ---•--•-----------------------------•--------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------.------ ------------- --------------------------------------•---------------------•----------------------------••--•------------------------------------------------------------- --------------------------------------------------- -----------------=----------------------------•------------------------------- •------------------------- -----------------------------•------------•----------------------------------•--------------- I hereby certif that I have prepared a plication and that the work will be done in accordance with San Joaquin County ordinances,'Sta s, and rules and, ati s of the Sang quip Local Health District. (Signed--- --------- ---- --- •--- ---------- --- - ------------------------------------------------------------------------- ------------------------.(Owner and/or Contractor) C B ------------------------------_.�4-- -----------------------------------(Title)------------------ ---------------------------- --------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ----------- ------------------------------------------------ DATE-----//_ - -- REVIEWEDBY-------- --- ------ ------------- ---------------------------- DATE------------------ --------------------------------------- BUILDINGPERMIT ISSUED--------------------- --------------------------------------------------------- DATE------ -------------------- --------------------------------- Alterations and/or recommendations __:_ -------------------::: z4e - r---� ---- - -- ---E------of- ------ ----. ---------- - - - -- ---------- . -_ --- -------- ------- _ --- --- -------------------------------- FINAL INSPECTION BY:-------- - - . ..... --- ! ------ Date------ --------f -------------------- 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 ES-9-2M 10-52 Revised W-2300