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APPLICATION FOR SANITATION PERMIT Permit No. S._T.�__... --_ (Complete in Duplicate) /)DOS 44 / R-1- Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and ins{all the work herein described. This application is made in compliance with County Ordi a e No. 549. w JOB ADDRESS AND CATION. ---- ----- ----------------t�. � `Q..• �/Ll .1`_ d4__-' Owner'sName___ f- r� Phone --------------------- Address, ------ 1-��►.__^.A4__ _M.- Contractor's Name___________________ ----------- ----•------------ Phone----- ----------- Insfallation will serve: Residence i� partment House ❑ Commercial p Trailer Court p Motel El Other ❑ Number of living units. Number of bedrooms --Number of baths ---V_ Lot size ___- Q. 2.� ---------------------- Wafer Supply: Public system ❑ Community system El Private Depth to Water Table -------- ft. Character of soil to a dep{h of 3 feet: Sand ❑ GravelPd Sandy Loam [)4 Clay Loam ❑ Clay [] Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No [x New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se Tank: Distance from nearest well Q_:T Distance from found ion_ _ 5( -- - y ��-------.MaP___ ial----------- No. of compartments------- - -------- ----Size---,3_r4- - --Liquid depth------- .-__----Ca acit Dis osal Field: Distance from nearest weElfpC?,1L Distance from foundati n.__ Q_.__.--- to nearest lot line-----_ _ Number of lines-------I_-- -- ------------ _Length of each line----�__Q_. __ '- �------- 1_� �� Width of trench- .�Q- ---------------- Type of filter material___-M _-Depth of filter material-_-1 --------------Total length-----6.Q---- Seepage Pit: Distance to nearest well------ ----------------Distance from foundation-----------------...Distance fo nearest lot line____._.._________ Q ❑ Number of pits----------------------Lining material---------- ----------..Size: Diameter-----------------------Depth- ------------------------------- `u Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining maferia -- El Size: Diameter-------- -------- Depth----------------------------------- Liquid Capaci.tY- ga--- Privy: Distance from nearest well-____________________ --_.....____.___-Distance from nearest building ❑ Distance to nearest lot line___________________________________-- Rg odeling and/or repairing '�l_ ! 41� + �y RQ----�--- i fw r f f -- �'� .e_. (-1�--------- ----- _ _----------------------------•----------------_----•-•_---------------------------•-----•-------•--••------•----------------------•----------------------------------------•-----•---------------------------------- I hereby 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 an reguslations of th6 San oaquin'Local Health District. el (Signed) % _---- -- {Owner and/or Contractor) By:------------------------••--------•--------------------------------------------------- ---------•------------------------- -------{Title)--------- -----------•- ------------- ----- O (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_ REVIEWED BY -------- - - DATE -`� ------- -- ----------------•-------- BLIlLDlNG PERMIT ISSUED ------------ ------ ------ DATE--------- -- ----------------------•------- --- --------------------------------------- Alterations and/or recommendations_ -`---'- ----•----------- ----------------- -----••- ----------------------------- -------------------- - FINAL INSPECTION BY_____________ ___ E 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 J0-52 Revised W-2 1D0 "