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`f APPLICATION FOR SANITATION PERMIT Permit No. :r a a, (Complete in Duplicate) dyr Date Issued __._--____ Ab Applica+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 OrdinPr-e No,. S49. JOB ADDRESS AND LOCATION___- - :. 4f- - ---- 11:I ----- f. Owner's Name---- _ Phone - - /Address - ---- -----------------------------------------------------------------�- --------------:--------•----------`------�---a -----� -�--- rl Contractor's Name ----- -l0-` -�------------•- -- . Phone Installation will serve: Residence `Apartment House ❑ Commercial ❑ Trailer Court El -Motel ❑ Other ❑ !_ 2 -- Number of baths ____ Lot size ___L � Number of living units: __�____ Number of bedrooms - -�----�----1--'�"='�----� ---------------- Water_Supply: "Public system !'Community system ❑ —Private ❑ 'Depth to Water Tableft. �- Character of soil to a depth of 34eet: Sand ❑ Gravel ❑ Sandy Loam [3 Clay Loam ❑ Clay ElAdob Hardpan ❑ 1 Previous Application Made: Yes ❑ No2 'I 16w Construction: Yes ❑ No 1 - TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tan : °Distance from nearest well_______________'Distance from foundation__.__'------.:==__.Material------------------------------------------------- _ No, of compartments--------- ':- Size--------•----------------------Liquid dLI6 h---------------------------Capacity----------------------- --isposal Field: Distance from nearest well______________.Distance from fo ndatiosi---------------------Distance to nearest lot line___>._;-.________ NumbWo'f lines-_---------------------------_--Length rof-eachNin- ---------------------------.--Width. of trench----------------------------------- T o filter material----------------------Y_ Depth of filter material------------- TotaI#length-------------.__-------------------------- Yp .�_ - - ' " ( _�__.Distance to nearest lot line--_f Seepage Pit: Distance to nearest well-_Distance from foundation____. ... _. O Number of its------------- Lining material.- e,�--Size:'Dia mefer-- -•• .- -�_------Dep th----- -----.------------- P n /----- . 1' , .. Cesspool: Distance from nearest well----_------------Distance from foundation_____;______ ._._.Lining material- -_:__-._____.___________________ �} ❑ Size: Diameter--- ---=------ Dp -------------=; :,__ e th:------------ ---------------- ----Liquid Capacity----1-----------------------gals. Privy: Distance from nearest well-----'-'---..---'--------------------------------Distance from nearest building----�------------------------------------------------- Privy: stance ❑ s' Distance to nearestilot line:- - _ ==----- ----- --•---- ----------------- - ------ 1 i - I ' Remodeling and/or repairing (descrbe}: - ---------------- - �4 - - tt �. r -- - ------ -------- ------------------------------------- ------------------------------------------------------------ -------------- --------------------- a _ 1 I hereby certify!,that I have prepared this application and that the work will be done in accordance with San Joaquin,,County q I ordinances, S to laws,' and r es and regulations of the San Joaquin Local Health District. .. T _ ---- --------------------------------- Contractor (Signed) -- --------- - -------------- - -- t - BY? �" -- - -------------------------- -- ------- -- {Title) (Plot plan, sh ing size ofrlot, location of system in relation to wells, buildings,.etc., can be placed on reverse side). ' i T * FOR.DEPARTMENT.USE.O.NLY t F --- DATE------. ... ------------------------------------------ APPLICATION ACCEPTED $Y__ __________ _____-__ . • -- ----------------- DATE `- , t REVIEWED BY --------- ----------------- ' _: _ :._ I BUILDING PERMIT-ISSUED----=--------------------- -- --- -- ------------------------- DATE.---••- -=-----------� - Aiterations and/or.recommendations_______________________ ... `. : k -------------------------•--•--•-----------------•------- -----------------------' --' ---------- -`-•---- ------------- --------------- ----------------------------------------------------------- FINAL INSPECTION $Y:~` ------'-------'-`a� Date = -'= - ._. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street Soo West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M Revised W-2140