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' APPLICATION FOR SANITATION PERMIT Permit No. .....'� -� .d --.� f (Completein Duplicate) Date Issued .__%S pplication is hereby made to the San Joaquin Local Health District foraermit to con This application is made in compliance.with County Ordinance No. 549, p construct and install the work herein described. JOB ADDRESS ND LOCA rIQN__- _, _-a , ------------ ----------------------•--------------------- -•------ - -•------ ------ Owner's Nam ___.____ ----------- Phone -- ------------ Address--------------- ------- ' Contractor's Name._ ___. __ - -----------------•---------------------------------- ---------. Phone-,----------- Installation will serve: Residence Apartment House ❑ [_1 Commercial Trailer Court [] Mof5l ❑ Other ❑ Number of living units: --- ---- umber of bedrms a- Number of baths _� _" p5 f . oo_ ____ Lot size Water Supply: Public system comm�n-ity stem �._.._.Privatee ' -" I y y ❑ ❑ Depth to Water Ttable ........ ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ SandyLoam ❑ ClayLoad❑ Clay ❑ Adobe E?/HardpanPrevious Application Made: Yes ❑ No ❑ New Construction: Yes. ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer s availabl w4Win 200 feet.) �f Septic jank: Distance from nearest well-----------------Distance from foundation--------------- Material _____"______.___"__-._____.____.__.._"____._. No. of Compartments----- -------- ize--------------------------------Liquid depth-- -----------------------capacity............... t ! Dispo�a Field: Distance from nearest well Distance from foundation__ __ / 1 ' �.�/o Distance to nearest lot I-na ----- Number of lines___ "__- .. a"Length of each line-------- ; Width of trench_._.__ '7 Type of filter materia e !f ,- -- pth of filter material-- Total length------------- ------------ 3 T' f __..,,w..,.,� .,_. �: _ Seepage Pit: Distance to nearest well----------------------Distancelfrom foundation-______-____--__-.Distance to nearest lot line__----..___---___ (� ❑ Number of pits------ � ------ �Lining material_ 4-,e-------- --- Size: Diamete -------------- --------Depth .._.. . .1 Cessp l: Distance from nrfest e1 fVDist'ane from f undation....____ �4 Lining material------------------- --- ----- ------ $izc: Diameter_-- -------------------Depth_ " -- Liquid Capacity------------------------•---gals. Privy: Distance from nearest well____ Distance to nearest not Line ------------Distance from nearest buildin ❑ _ ..............._- - ------- Remog Iing nd/or�repairin (describe):__j__. _ --------------- •------- 1 ------------•--------------------------------- ------- ------------- --A---- - -----------------------------------------•-------------------------•-------------------------------------- - - - - - hi - ----------------------------------------------------------- her certif #hat I have re ared #his a Y Y p p pp tion nd that hthe work will be done in accordance with San Joaquin County ordinances, S/tyatee}lawns,-'a-nd rules and regulations of the San Joaquin Local Health District. (Signed)-_- _'^�-----f��. � t � ( caner an r Contract �E t ----------------------------------------------------------- O B' 1 d/o °rI - - Tale (Plot pla , showing size of lot, location of system in relation to welll, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ----------- ------ DATE-:,/ -- REVIEWED BY - - - --- - DATE-----V -- - --- ---- ---- UILDING PERMIT ISSUED-------------------------------------------�-------- — ----------- ---- ,�. DATE --------------------------------------------- Alt--e--r-a--t--i-o--n-s-- and/or recommends#ions: ________"_..._ , --S------------ - It ----------------------------------------- -------------------- ---------------------------------------- -----------•---------------------------Dat-------------- - - FINAL INSPECTION BY __ ____ �3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100