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APPLICATION FOR SANITATION PERMIT ) " ' No. ^' (Complete in Duplicate) 3 Date Issued ss ed ,7 o-ra( Applicaa-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 Ordinance No. 549. JOB ADDRESS A D LOCAT ON�� . �^ -- Owner's Name -'-------s ------ -- Phone �z. =tom Address-------------------------------------------------------1 4 �'- ------ -------------- Contractor's -.----- --Name--------------------------- j -� --- --- ----------- ------------------------• •- -------------------------.. Phone_ Installation will serve: Residencex Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i -,_ ___ Number of baths - ____ Lot..size ____ .3-�::�! /_U�1 --____________________ Water Supply: Public system Number of living units: J----____ Number of bedrooms � ft E] Community system El Private K Depth to Water Table Xr Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy-Loam ❑ Clay Loam ❑ Clay ❑ Adobe a Hardpan [" Previous Application Made: Yes ❑ No1New Construction: Yes,,56 No ❑ 1w TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) m Septic,Tank: Distance from nearest well ------Distance from foundation___ ___________.Material______._____.__-_ .- 1_/C __ ---------- No, of compartments__ �_____________5ize ` _ �' X Liquid dep#h__,§- -__.________Capacit�A�_-_________ Disposal Field: Distance from nearest well_��__ Distance from foundation__Z-'?_______....Distance to nearest lot line---m. _----._ Number of lines-------- Length of ea t line___ - _ __. engWidth of trench_.-_ -- Type of filter material _ [.-_Depth of filter material___-___1Y Total length--- _, _ __________________.- �. JJJ / -;F_77 Seepage Pit: Distance to nearest well_. _�`p _____Distanc fr fo dation_ QQ-__..___Distance to nearest lot cine_________________ Number of pits Lining materiaN��i4 _.Size: Diameter--j-3. Depth .1-4.r ,.,.,-gesspool: Distance from nearest well------------ ---Distance from foundation------------------- Linin material,_.________-____._____--__________-_ ' , T TM F �' ;;.r Li uid-Ca aci# . ❑ Size: Diameter---=--- ------------- ` _Depfh--------- --------=--•--,_ ..._� _ -- - • _ �als.�.. Privy: Distance from nearest well---_----------"-------------------------------'._Distance from nearest building------------------------.-____..__.__ ---. ❑ Distance to nearest lot line------r------'--------------------------------- = - Remodeling and/or repairing (describe): ---------- ---------------------------------•-------------------------- -------------------------------------------------• ---- - ---------••---•------------ -------------•---------------------------------------••---------- ------ 4 -----------------------------------------------------_--------------------------------------------------------------------------------------------------------------------------«_____-____-_____--_____________________.____.- I herecertify t a have prepared this application and that the work will be)done in accordance with San Joaquin County ordinances, Sta a laws ruljad regula ons of the SandJoaquin Local Health istrict. (Signed) - ----- ------ - ------. ------- ------ Cont ctor) By-------------•_....................•------------------------------- --------------------- :. _ iy,Jju" [Title} (Plot plan, showing size of lot, location of syste: in relation t we![s, buildings, e)l can be placed on reverse side). ARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------- :------------------------------------------------- DATE------------- - REVIEWEDBY----------------------------------------------•----------------------------------------------------------------------------- DATE-------- ----- BUILDING PERMIT ISSUED - DATE_.- -- ---- Alterations and/or recommendations------------------ ---------•------------------ •-•-------------•-------------- ---•-------------------------------------•---------•--------••-----•------------------------- ---------------•--------------------------------------- -----------------------------------•-----------------_------------ -------------•-------•-----------------------------------------L------------------•--- ----------- ---•--------------•---------------------------------•-•------------•-----------•---------------------•------.._.._. 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 i ES-9-2M Revised W-2100 t