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APPLICATION FOR SANITATION PERMIT Permit No. 19. .-��)_- _. (Complete in Duplicate) Date Issued Applica*ion 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 C unty Ordinance N . 549. ` E JOB ADDRESS AN LOCATION ?--------- `.e-- -------------------•----- - --- •--- ------ Owner's Name414� ------ -- - - - --- ------ Phone......................-. Address ? _.._._.. . `•" -•-------- -A--• ------•... ..........�----`--------• - --------------------------------------•----------------------._.. Contractor's Name------------- --------------------------------------------------------------------------- -- •- -----------•----- Phone.................... .............. Installation -- - Installation will serve: Residence Apartment House ❑�/Commercial E] Trailer Court Elotel Other El 'Number of living units: _Number of bedrooms __`l_ Number of baths __-YLot size Water Supply: Public system ❑ Community system ❑ Private K, Depth to Water Tabl -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pybl'c sewer is 'able within 200 feet.) Septic Tank:, Distance from nearest well om foundation----.---------------Material---------------------------__--._._____________- ❑ o. of compartments- { Size Liquid depth Capacity ! Disposal ie4- i nce from nearest well-&4._Distance from foundati n __ _ ___.Distance to nearest lot I• pf (0-----_ ❑ N' ber of lines______._____._ Length of each line__- ,__1_ Width of trench_.___,__ _______________ Type of filter material.�T_ __ _Depth of filter material__A_/,x_ _. otal length-------- fin page Pit: Distance to nearest well-..._______._ ___Distance from.foundation---.---.....::.....Distance to nearest lot __ ___.____._._ ❑ Number of pits----------------------Lining material------------------,_'Size: Diameter----------------------- Depth-----------------------__-------- Cesspool: Distance from nearest well-----------------Distance from�foundation_t_„_.-i-----------Lining material-------------------------------------- ❑I Size: Diameter--- ------------- -- Depth-----------------------------------b..........I.,----Liquid Capacity- ,_- -------- :_:gals.. . Privy: Distance from nearest well_ :_ ____ _ _________________Distance from1nearest building-------------------------------- 3 ___..._ ❑� Distance to nearest lot line------------------------------------------------•----------------` s --------- WA9 � r Remodeling and/or repairing (describe):__ 7+d(,edf__ -44-t---- �- ` ...-••--------------------------------------------------------•---------•----•-----------••-------6f-----------------------------•--------•- ---------------•--- =------ ----------=------------------------------------•------_--.----------___--- ------------ R ------------------------------------------------- ■ x I hereby certify that I have prepared this application and that the work will be*done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)- - ------i ----------------------------------------------------------------- -----------------------(Owner and/or Contractor) By---------------------------------------------------------------------- -------------------------------- -- -•- ---• -----(Title)- --• -• -- ------- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- --- ---------- DATE REVIEWEDBY------------------------------- ------ --- - - ---- -- ------------------------------------------------ DATE-------+__ _BUILDING PERMIT ISSUED------------------ ( ----- ------------------------------------� DATE--------- -------• -•--------------------------------- Alterations and/or recommendations---------------- ---------------- --------------------------------------------------------------------•------------- -------------------------------------- ------------------------------------------------------------------------------------ -------------------- ------'------------- ------------••------------------------------------- ----------------- ---------•--------------------------- -----------------------------•----- •-----•---------------------------------------------------------------------------------- - FINAL INSPECTION BY=-------------------- Date-..-----y --- ---------------- 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 ; ' Revised W-2100