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APPLICATION FOR SANITATION PERMIT-` Permit No:�/ (Complete in Duplicate) 6 (� Date Issued 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 Ordinance No, 549. JOB ADDRESS AND LOCATION------- - / ----------4��1-I_z� _�4__l) Owner's Name--- --------------------:1 Address xL - ------------ ---- -------------------------------- ----- Phone-17-1-7-a6-47 r-_�f_4/ ------ ------- z------VV9e - �_... -•-•------- Contractor's Name .. - +4 '' � - --------------- Phone- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: Number of bedrooms ._�" umber of baths of 04 ___ size ___ 40 ZaLl Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E] t Previous Application Made:- Yes ElNo New Construction: Yes [_1 Nola TYPE OF INSTALLATION AND SPECT &CATIONS: T (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation---------------.___.Material ❑ No. of compartments--------------------------Size--------------------------------Liquid clepth-------------------- Disposal Field: Distance from nearest well _------------- Distance from foundation--------------------Distance to nearest lot line________________ ❑ Number of lines----------- °-----------------Length of each line------------------------------Width of trench.-----------""_"-- -NZ Type of filter material-------------- -------Depth of filter material-----------------------Total length---------------------------------------- Seepa a Pit: Distance to nearest well._ VPIV `----Distancel. rom foundation_ _0._-Distance to nearest )of fid _ e ____.._ Number of pits._Q/ "-----Lining material___:___fj!` lrC,1'e_ Size: Diameter__'��"....... -De tn_ --� ' Cesspool: Distance from nearest well----------.------Distance from foundation--------------------Lining material----- ----------- ---------- --- ❑ Size: Diameter-----'--------------- .----------------Depth--------------------------------------------- -- Liquid Capacity----------------------------gals, Privy: Distance from nearest well___________-_----._____. -----------------------------Distance from nearest build;ng-------------------------- r El Distance to nearest lot line---------_______________-__.._._ Remodeling and/or repairing {descrilaeJ:___ ,." ----------• -------------•-.---------•------------------ ------ + '�.__- ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, St�11p�and_ml and regulations of the San Joaquin Local Health District. (Signed) - ------••------- -A... / '� J-�'1 - // "° ------------------------------ (Owner nand/or Contractor) By:------- ---... LCr, - -----------(Title)----- �, Gr - (Plo# plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placied on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- DATE----- = . REVIEWED BY-------------- ----------------- Y-------------- --- ----------- -- ��--- -:��----- - ----------------------------------------- -- ----- - DATE------- - ----- ------------------------------- UILDING PERMIT ISSUED---------------------------------- - ------------ ----------------------------------------- --------- DATE------ -- ----------•----------------------- - - � Alterations and/or recommendations_ --------•------------------------------------ ------ -- --------------------------------- - FINAL`=.1N5PECTION BY: k. - Date -------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT L X130 South•, American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California fi d ES-9-2M 10-52 Revised W-2100 9 ! L