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1 I APPLICATION FOR SANITATION PERMIT Permit Na. .�D_g Q (Complete in Duplicate) Date Issued x�41� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work This application is made in compliance with County Ordinance No. 549. k herein described, JOB ADDRESS AND LOCATION_______._ Owner's Name- --��-rye--- --------------------------------------------- ------------------------- -----•------"------ ---------------------------------------- ------- Add - Phone e� - --•---------Contractor s Name------ --------------------------- ---------•- _ Installation will serve: Residence ----------------- -----------•-------------------------------- Phone----------------------------------- Apartment House ❑ Commercial ❑ Trailer 'Court Number of livingunits: -_ ❑ Motel ❑ Other ❑ .0-__ Number of bedrooms - - Z Number of baths - Water Supply: Publics stem ---�- Lot size ------��_�,j� � ' Y ❑ Communit system ' -�----- Y Y ❑ Private Depth to Water Table __-.____ ft. � Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Cla Loam Previous Application Made: Yes No A Y ❑ Clay El Adobe Hardpan ❑ TYPE OF INSTALLATION AND S ECIFICATIONS;Construction: Yes ❑ No ❑ (No septic tank.or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well___ -----------------Distance from foundation_______.____- ❑ o. of compartments-------------------- -----.Material------------------ --------"-------------------- -f Size_'I -- ---=---Liquid depth--------------- ----------Capacity._ Disposal Field: Distance from nearest well._..- f�_" - i --- .*.Disfance from foundation____ - ._.bistance to nearest lot line____., _, ® Number of lines___________ Length of each line--- `�-- ('"Width of trench.------ ----------------- ----------------- --- ---------------- Seepage " Type of filter material"- �0 _-__.._ Depfih of filter material___.",l�" See a e Pit: - ..........Total length------- +� d ---- p 9 Distance to nearest well_.__--_--- Distance from foundation--------------------Distance to nearest lot line "__-__ Number of pits----------------------Lining material---------- - Cesspool: - -----------Size: Diameter--------- ------------,Depth----------------------p Distance from nearest well------------- Distance from foundation El material----..----_---. ------_------ t " ElSize: Diameter-------------------------------------- Depth -------------- •-- -�•------gals. Privy: Distance from nearest well ----------------------------------------------Liquid Capacity � ---------- ---------Distance from nearest buildin Distance to nearest lot line-------------- g-- Remodeling and/or repairing (describe):--------------------- - -- - ----------------------------------------- ------------------- - .- -------------------------------------------- ----"--------------------- - ------------------------- ----------------------------------------------------------•---------------------•-------------------•-------- ------- ------•----•------------- ! hereby certify that] have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State an rules anol regulations of the San Joaquin Local Health District. (Signed).,-Z ------------------ I - ---- - - --- -- ----------------------------------------------- -------By:----.----••----_- --•------------------•----------- - Owner and/or Contractor) - - -- - -------------------------------•---------- - - - - ---- ------(Tit]@)--�---------------- -- ---- � (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FO PARTMENT USE ONLY APPLICATION ACCEPTED BY_____________ REVIEWEDBY------ ------------ ------------------•------------------------ DATE------ --------------------------- ---------- --- ------------------------------------------------------------------ DATE BUILDING PERMIT ISSUED-------------------------------- - -- - ----------------_-_-- DATE A terations and/or recommendations-------- ------ RNAL INSPECTION �j -- ----------------- Date--.---- `a- 7 f iK'5's - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 IVor}6 "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100