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APPLICATION FOR SANITATION PERMIT Permit No. ------ - d_----___.- (Complete in Duplicate) o),- / Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to constructandinstall the work herein described. This application is made"in compliance with County Ordinance No. 549. JOB ADDRESS AND'LOCATION..._.r . ..........e........ ------------------------------------------ ._ , Owners Name___.___ . ' ._. .ter.. :.. ----- --- Phone------------------------------------ 2 . � ---- ---- -- -- - Address ...... . < --------- -------------------------------------------------------••--- f Confractor's Installation will serve: {Residence C4 Apartment House E] Commercial ❑ Trailer Court ❑ Motel ❑ Other El' P Number of living units: :f-_ Number of bedrooms __ Number of baths ___ _ Lot size _________________________ . Water Supply: Public)sy'ste'm E] Corr reunify`system E] Private DO Depth to Water Table�°r' ft. Character of soil to a depth'of 3 feet: Sand [❑ Gravel ❑ Sandy Loam ElClay Loam E] Clay ❑ Adobe( Hardpan E]Previous Application Made: Yes ❑ t, New Construction: Yes ❑ No rV ter. .: TYPE"OF INSTALLATION AND SPECIFICATIONS: # (No septic tank!orcesspool permitted if public sewer is available within 200 feet.) 1 p No: of compartments___._._,_--- Sizey „ - foundation----- -_----:_---- Se tic Tank: Distance from nearest well, _ '_ _Dis+ante from fort �� c� ¢7 .__,Liquid depth---•--6--_ - --------Capacity------�--;�v------- Disposal Field: Disfance from nearest weK_' �_--._' "' �-..---._ Distance from foundation_____-__ --------Distance to nearest lot line_______-�'�-_�____ [ Number.of. lines-____'.1___._._____ f ength of each line_____-___ - _ Width of,trench--- '_ ----------- Type f------------- ttaa M Type of filter material— tDepth of.filter.materiai____._ -T. ___Total length___-._1.:-?______________________ ..tee-.. `a. J + ` r_._ - -----__. ` 1' e �. I g �� Distance to nearest lot line___ __:�.__ ZJ Seepage Pit: Distance to nearest well___ ,r,��: �__Distance from foundation.__.. _ b [� Number of its___ __ ___Linin material -��<-+size: Diameter____-- _`.�---.Depth ;7_ j ___________ y Cesspool: Distance from nearest well___=___-____I`_:Distance from foundation___.____..._____._.Lining material__-__-__..____-- _-______- Size: Diameter_ Depth ---- -----------------------=----Liquid Capacity----------------------------gals. r{ Privy: Distance from nearest well__________________ __________________- -_--._.__Distance from nearest building--- __- ❑ •T ` - ; -------------------------- - .. .. o _...� a...r .a.-w, �r is ance'to'nearest of line-------- --� �-��-- '----- -- - - ---------------- ---------- Remodeling and/or repairing (describe):--------" ----------------;--------------------------------------------------------'--•-------------------------------•-- ---•-----= �, s,�-',r -------------------•-------------------- ••------------------------------'•----•--•---------------------------------------.----------------------------•------------------------------------------------------------------------ -------------------------------------- I hereby certify that I have prepared +his.application and that +he work will be done in accordance with San Joaquin County ordinances, Stag laws!'and`rules and regulations of the San Joaquin Local Health District. (Signed)---._'... ------------- '----------------------------'------------------•------- = (Owner and/or Contractors c B ' r= -.. :.-+ . 1 _--- _. .Title__.... Ely: (Title) plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE-ONLY APPLICATION ACCEPTED BY---- ----- DATE --r - REVIEWED BY----------------------------------------- ------------------------ - DATE = -------- BUILDING PERMIT ISSUED--------------------- -- . ---- ----- DATE.------------- = Alterations and/or recommendati ons------------- ----------- _ ___ _ -------------_---_----.--___-_••- ' ------- --------- --------------------------------- ---------------------- ------------------------ ----------•--- ------------------'- ---- -- ------ -------- -- -- -- ---- --------- ------------ ----------------------------------------- _.....0 FINAL INSPECTION-BY:. -_ -----•-----------�--:--- Date__-:,/_L_._"__ _ l SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street l 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California # Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100 rt