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Permit No. APPLICATION FOR SANITATION PERMIT .---' S --- �� 1 � (Complete in Duplicate) Date Issued Application is hereby- ade 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. I JOB ADDRESS AND LOCATION s 4 - ------------- --------- ---------------- ------------- - Owner's Name---------------• ------------G '" - --——--- -* Phone. Address----------------------------------- -------------- Contractor's ---- ----- Contractor's Name----------------------- ----------- - --------------------------•-------------------------------- Phone.-----�.�:--- -Q7-- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1.---- Number of bedrooms ---(--- Number of baths ----L Lot size ------------ Water Supply: Public system ❑ Community system ❑ Private_ Depth to Water Tabl..-?-.o_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobep Hardpan ❑ Previous Application Made: Yes ❑ No 5�,_ New Construction: Yes 4 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic ewer is available within 200 feet.) rest well- -Distance from foundation-12-1------_.Material--- Septic Tank: Distance from nea leo. of corrpartments..-_as.-.-...----�----Size-- - - -----Liquid depth---`-I �'--.�-------------Capacity----- -�----- --- Disposal Field: Distance from nearest well__ -___..-.Distance from td'Undation_-/-f7-------------Distance to nearest.lot line--------- Number of lines----I-----------------------------Length of each line-l-Q----------_-_------.Width of trench.27"ctc,_.--- IJV Type of filter material_ s,"- .......Depth of filter material--- -__Total length-------------3 ...A-V o___ ----__-- Seepage Pit: Distance to nearest wel1q.0_------------Distance f o�m foundation-_--��---.__.Distance to nearest lot line.-_-- .------..- IN' Number of pits-- -----------------Lining material ----- -- ------_Size:aDiameter--- -- -y--------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 thb ave ¢"r'epared this application and that the work will be done in accordance with San Joaquin County ordinances,". tate laws, ules sand egulations o the San Jotuin Local Health District. -, •- ---- -- •- -- - -- ------------------ (Signed) �� 6ntrdGtOr� -------- C B ' -------- - :` (Title Y•• (Plot plan, showing size of lot, location of ste '", elation to wells, uildings, etc., can be aced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ -�- ----- �---- ------------------------------ --- DATE-------- =? -� REVIEWEDBY--------------------------------------------- -------------- -------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- ---------- DATE------------------------------------------------------------- Alterationsand/or recommendations------------------- ----------------------------------------- ------------------------------------------------------I------------------------------------------- ------------------------------------- ------------------ -- -•----•--------------•------------------ ------------------------------------------------- --------------------------- Date------- ! -- --------------- FINAL INSPECTION BY--------------------`.---- -----�- - ` -�----- 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 10-52 Revised W-2100