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APPLICATION. FOR SANITATION PERMIT Permit No. ... ��e a 1p (Complete in Duplicate) Date issued Application is here, 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_____________Ve ----- Owner's Name ---•---- - - ----------------------------------- -------- Phone----------------------------------- Address------------------------------------- ----------------------------------Address------------------------•---------------- -- - --- - ------ . - Contractor's Name ---- --------•-- --a----f- .•---- --- = = Phone 'r Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _. __ N ber of bedrooms _Z. Number of baths j____ Lot size ------- _. -------•- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tablft. Character of soil to a depth of 3 feet: Sand ❑- Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay 0 Adobeardpan ❑� Previous Application Made: Yes ❑ No A"'Now Construction: Yes to ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) an Se tic Tk Distance from nearest well_________________Distance from foundation--------------------Material ______..___.__________._______________-__-____. p �. No. of compartments---------- ---------------Size---------------------------------Liquid depth-------------------------_Capacity-_-_ Disposal Field? Distance from nearest weli__-._________.__.Distance from foundation_______________...Distance to nearest lot line----------------- • Number of lines------------------------------------Length of each line-----------------------------.Width of trench.--------- epth of filter maerial___ _________.Type of filter material______________________ __-_____ g ____-_-________. ______________ __. See a e Pit-., Distance to nearest well- Y � pistance €rom fou dation___Z�,._-.Distance _ to nearest lot line_-_�S -__--__ ❑ Number of pits--- --L:!---Lining material(," - .Size: Diameter----- - 'r----- Depth-____- ?_ '" Depth-_.?A�--- Cesspool: Distance from nearest well_________________Distance from foundation---------------------Lining material------ �•A ❑„.� - Size: Diameter----I =------- ------- ---- _-_.___Depth-_'' = - Liquid-CapaeitY- '- .__gaTs. Privy: Distance from nearest well-------------------------------------------------Distance from nearest ❑ ------ -- ----- -------- building. _._____-.___Distance to nearest lot line--------- -------------- - y Remodelingand/or repairing {describe)---------------------- --- ---.--- ---- / ------------------------------ -------------------------------- - -------- ---------------•-. ---- • ------ ---------------------------------------------- { --------- ----------------------- ------------------------------------------_--- ------------------ ------- I herebycertifythat I have prepa ed this application and that a work will be done in accordance with San Joaquin County ordinances, State law an rules and r ulations,of the San J aquin Local Health District. q (Signed)---- At * .� : ontractor)______(Ownet and/or By: -- �.' --------------------------- Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be pla ed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------=------- _ DATE REVIEWED BY--------------------------------- S ------------ ��=�' Z------------ --- ; --------- - ---------------------- -- �--- ------------ ••----------------------- DATE------ -----•----------------- ------------------------------ BUIL DIN PERMIT ISSUED----------------------•--------------------------------------•--------------------------------------- DATE----- - -------------------------------- terations and/or recommendations:__----------------------------------- --------- •-.-------------•----------- 1 FINAL INSPECTION BY: �r� L7re%2 - "` Date _ <- - SAN JOAQUIN LOCAL. HEALTH DISTRICT 130 South American Stroef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100