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APPLICATION FOR SANITATION PERMIT Permit. No. -j--2------- (Complete in Duplicate) Date l�ssued __-f--l Application is herebymade to the San Joaquin Local Health District for a permit to construct and install the work herein described. Thiapplication is mde in compliance with County Ordinance No. 549. JOB ADDRESS LOCATION--- I Owner's Name- _-tf�� "i � �� - ---------------- -- Phone -tf_ ----- �-�` ----1�� --- aw �M Address. _ � . - 5 .__ --f----- - -- --�--= '- °. � I� . Contractor's Name -- -------------- ----- --- ----- - - --------- - Phone•'-------•-------------•----------- Installation will serve: Residence ❑��-"`Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __�-__ Number of bedrooms __- -- Number of baths ---)-- Lot size __,,_ll_ _ .__ __ ; +'__ -- ------ Water Supply: Public system ❑ Community system ❑ Private �y"Depth to Water Table 7_-0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ElSandy Loam [} "Clay Loam E] Clay ❑ Adobe ElHardpan El Previous Application Made: Yes ❑ No 8--New Construction: Yes g�-"No ❑ TYPE OF INSTALLATION,AND.SPECIFICATIONS:,,,.. - (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se teci-nk: Distance fro near ts}_Weld _____ " D,e/ce r ndati� u d depth__Ma ial_____.___C-----------------pNo. of comp - - s-- Rapacity Disposal eld: Distance from nearest wefl.9b-s;R-`{___-Distance from foundation_ -` -----___ Distance to nearest lot l.ine__�_�_ '_- Number of Lines---- ---• -----------",Onqfhpf each line-- --# -___--f-- .Width Oftrenh,t?- ---------------Type of filter material_- '-- � of filter material-------/IY^_'Totai length---:I�------ -•---------------------- p l Seepage Pit: Distance to nearest well------------ ------Distance from foundation________-______---.Distance to nearest lot line_______-______-- .�Y ❑ Size: Diameter------------------ Depth--------------------------------- Number of pits_______________------Lining material__-__________________ a Cesspool: Distance from nearest well---------------_Distance from foundation---------------.- .Lining material__-_____.________________--_-____s. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capaci I,--------------------- gals. Privy:.:.�. _. �. Disfance=from.nea,rrest we.ll----------•--------------------------------------Distance from nearest building--- -_--- -•_-- -- _ lot line-- ---- ------ --- - ❑ Distance to nearest Remodeling and/or repairing (describe)------------------------ -------•----------------------------------------,•------• -------I----------•----------------- --------------------------- ---------I------------------------------------- ------------ ------- -------------------------- ---•----------------------------------- ------------------------------------- - M ----------------------- -------•-•------------------- ---------------------------------------•--------------•-------------------- ---------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sia a aws, and rules nd regulations of the San Joaquin Local Health District. Owner and/or Contractor ate--I----_._ -,,,-.n------ ----- -- -- � � ) (Signed]------- - By:-------------------- -- ------------ e� = 11 (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverie side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B ---------- - ------- - DATE = �� ..._ -- - -------------------------------------- REVIEWEDBY------------------------ ----------------------- --------------------------------------------------------- DATE BUILDING PERMIT ISSUED------------------------------------ ----------------------------------------------------------------- DATE-------------------- M------------------------ ' Alterations and/or recommendations---------------------------------------------------------------------------------------------------------- �IM -------------------------------- •------ ------------------------------------------------------------ # ----------------------------------•------------------- ----� ------------------------------- ---------- - ------------- --- ------=------------------------------- ---- --------------------------------------------------- --------- - : FINAL INSPECTION BY:--. Date------------- ------ --------------------------------- 7 --------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT l 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street F Stockton, California Lodi, California Manteca, California Tracy, California k ES-9-2M 8-51 Revised W-2100 F 9