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0�' APPLICATION FOR SANITATION PERMIT Permit No. -_- -- I [Complete in Duplicate] / 11"0444_6 A.. L-Ij 4 - Date Issued __-- l 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 wit County Ordinance No. 549. ------------JOB ADDRESS AND LOCATI N--. - --------- -------------- ' VOwn ------------- -----------•---------------- - - - ---- - er's Name-------- -------- �.--•- -- --- -------------------------------------------- $,-------------- P -Address------------ Contractor's Name------ r- -------M ---_- ---------............. Installation will serve: Residence Apartme House ❑ Commercial ❑ Trailer Court [] Motel [] Other p Number of living units: _-l---- Number of bedrooms n5_. Number of baths _/--- Lot size _-_-_--_-- -_-___---_ Wafer Supply: Public system E] Community system ❑ Private,& Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoIV New Construction: YessA No ❑ } TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu61ic sewer is availa6le within 200 feet.) Septic Tank: Distance from nearest weil__�_<2---Dista e fr fou ation---__-_-- Material -----•--------- J No. of compartments----------�---------Size_a_ _ x-_ ...-Liquid depth__-------- Com. __-_--Capacity_. 0_�< Disposal Field: Distance from nearest well.- _O"__-Distance from foundation_-�_'_S_____--Distance to nearest lot line -----_-- - Number of lines----___---_ Length of each line-------------------�__---.-"Width of trench--_7- 7�"---_ - _,.- - Type of filter material- ___ - Depth of filter material--_ __ "..---_ ------Total length----•-1---�-4----------------------- Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line ❑ 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 ❑ Distance to nearest lot line---------------------------------- -------------------- Remodeling and/or repairing (describe):------------------------------------------- ` I hereby certify that I have"prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State law. and rules and regulations of the San Joaquin Local Health District. (Signed)----------- -- - --------- -..--____-(Owner and/or Contractor] By:--------------------------------------------------------------- ------------------------------------------------- "--------- -- ---------------(Title)------------------ -------------------- ------ ------ - (Plot plan. showing size of lot, location of system in relation to wells, 60d'Ings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLICATION ACCEPTED BY".--__-._-_-. _ _ DATE--------- _ REVIEWED BY- ---- F �j - --- ----- ------ -----------•------------- ----- DATE._-----K / r BUILDING PERMIT ISSUED-------------------------- ------------ --------------- • -------�--•- ----•-----. DATE-----------•----------Alterations and/or recommendations---------------- -------------------------------------------------------------------------------- ' -/-- ---------------•------------ FINAL INSPECTION BY:.�--------------------------------------- Date_---.-�..- 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 : Revised W-2100