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APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate Date Issued g`/lo 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 Ordinanc No. 549. JOB ADDRESS PD LOCATION___ _ r Owner's Na ---- . ------------ Address------ , -.-�e-R/--`- -- ----------`--�------------------------------------------------------- �t�, } � • -- _ --------------- ----------/ Contractor's Name--------------- -- -----•---- Phone Installation will serve: Residence Apartment House ❑ Commercial 0 Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-____ Number of bedrooms --.7o,--Number of baths __ ____ Lot size --- --________ __ Water Supply: Public system pP Y� uy ❑ Community system ❑ Private 0 Depth to Water Table -------- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No V New Construction: Yes �J No E]TYPE OF INSTALLATION AND SPECIFICATIONS: '1 (No septic tank or cesspoof-perinittedif public sewer is available within 200 feet.) - - - Septic Tank: Distance from nearest well-2- Distance from foundation___ZVMateri I-- No. of compartments--------+"fC--------Size--,.3_A- --, •--I- Liquid depth--------- ------___Ca acit r p y--•-_0__ Q- Disposal Field: Distance from nearest wet#----- -Opistance from foundation_________-.Distance to nearest lot line._! __.____ Number of lines---------------/-________-------Length of each line________+ i_. "'__._.Width of french--------- - _________ Type of filter material_ 6__ . _ _ __ "� Yp .__Depth of filter material Total length______________ �•_„�---_--- Seepage Pit: Distance to nearest well----14!x_------Distance from a at' n__ ��'' Distance to nearest lot Number of pits--------�-------------Lining materia�fly�lf�?�_ _ -- : Diameter-6_X__$_)(- ]epth-----_- --- ----------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----------------- ________.___.___ ' -- Size: Diameter--------------------------------------Depth--------------------------------------- -----------Liquid Capacity--------------- gals. Privy: Distance from nearest well----------------------_--------------------------Distance from nearest buildin ❑ Distance to nearest lot li g_ - �y Remodeling and/or repairin [describe ______ _________ ------------ _ �Ae__ g f _ 1________ _______c� .�.�- Zr - ----- f� - ------ ----------------- -•------------------------------------ -- -- -- -- ------------- --- ------ - ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulatio of the San Joaquin Local Health District. (Signed)---- �----- -------- --------- --- By:-----------•-••- - . ner a tor) N ---------------------------------------------------- - ---- ------- -{Title)------ ------------------------------------------------(+gid , (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---------------- -------------- - ,. Rt------------------------------------------ ------- --- ----------------------------------------------- DATE---- ' -------------------------- UILDING PERMIT ISSUED---------------------------------- --------------------------------------------------------------- DATE_ Alterations and/or recommendations:-._'--�-------- = ---------------------- " =- ' - T- -, ---------' '---------------------------•----------- - -- ------ ------•- ----- ----- -------- -- ---- --- FINAL INSPECTION BY:_ --- - -- -- Date ------ -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Street Stock+on, California Lodi, California Manteca, California Tracy. California E5-9-21vl B-51 Revised W-2100