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x APPLICATION FOR SANITATION PERMIT Permit N . �f (Complete in Duplicate) - Date Issue _. _-S'_}� Applicaa•ion is hereby madelto 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. Ate/ I O� ADDRESS AU � k LOCATION" Owners Name-------- - ----:. Phone - ---------------•------------------------------------ -- - ------------- �; f 6 Contractor's Name----- - [- - Phone" Installation will serve: Residence ®"A_partment House El 'Comm'ercial [j/Trailer Court E❑ Motel El Other E]Number of living units: "� Number of bedrooms _-�- Number of.baths _�--_ Lot size _"_SS .Zo_o ----------------------------- F .s ,r Water Supply: Public system ❑ Community system ❑ Private [EyD.ep�, th to Water Table y/ ft. Character of soil to a depth`of 3 feet: Sand El Gravel F] .Sand' Lorne❑ 'Clay Loam El Clay El Adobe�ardpan E] Previous Application Made: IjYes ElNo [t��ew Construction: Yes [B- —o '❑ r TYPE OF INSTALLATION AND SPECIFICATION "" } Septic Tank: Distancellspool permitted if public sewer is available wif irr 200 feet.)'. Na septic tank or cesspool from nearest well"/_XXC. Distance from foundation_- . t CC ------- Material-------------------------------------------------- A, [� No. of compartments-------a----------- 3 --X- Size yb Liquid depth --'-r---------------Capacity-/Gn" isp sal Field: Distancellfrom nearest well-----------------Distance from'foundation-----------1"" Distance to nearest lot line--------------- r�y Number of lines-----------------------------------Length of:each line----::--------------_--_-----Width of trench.-----------------___--- (�Jf" ------ -� Type of filter material-------------------------Depth of filter material'w'_.___. -_"""""_Total length"""--__"""""__-"""""_"__"""_"_""_"""-,` eep a Pit: Distance 'to nearest well-----__--------------Distance from foundations___""_ .-- Distance to nearest lot line""___--"""--"-_-" to i Number of pits---------- -----------Lining materia l-''-.................Size: Diameter------------------ --..Depth-.----------------------____-- I! 01 11 Cesspool: Distance;lfrom nearest well------------------Distance from foundation-----------I--------Lining material-------_--.---------_." ❑ Size: Diameter--------------------------- ------Depth-------------------------- ?__-Liquid Ca Capacity ----- . p Y from nearest welf�--------------------------------------------- from nearest building------------_-------____-- Distance ' Privy: . Distance .to nearest lot line__ ________ - Ip r --------------- - •----------------------------------------------- Remodelin and/or repairing' describe :"" 7)'_ •nl a. �� �� - i- _' .^- - .. I hereby certify that ('have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. y} . r ` (Signed}._- ---:"4G + o$Y: � .,Contractor) ------------------------------------------------(Title)- - ------------- (Plot plan., showing size of lot;location ofstem in relation to wells, buildings, etc., can be placed on reverse side). .k i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- DATE_--------_--___-•- _ - — -------------------------------- - -------------- ----------------------------- �f � = REVIEWED BY---- -------------------�`- - -- - ------------ ------------------------------------------------ DATE ------------ -----------•---BUILDINGand r ITISSUED D--- --------•-----------------------•------------------------------------------------ ------------ DATE. Alterations ations------------------------ ----------•--------- ----------------------- •-------- -----------•-----------------------------•-•--- 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 it ES-9-2M Revised W-2100 t 11