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APPLICATION FOR SANITATION PERMIT Permit No,_11'-7...7-- �J( (Complete in Duplicate) r IDate Issued �/Application is hereb ade to the San Joaquin Local Health District fora e This application is ade in compliance with County Ordinance No. 549. permit to construct and install the work herein described. JOB ADDRESS AND LOCATION..........2 �y Owner's Name----------------- _._Z/ 10 „ jaa� s --.--------------- -------------------- ------------------------------------- --- Phone Phone a_-^ /-tf Address 41- - Name ... ` . ,'---------------------------------------- Phone------ Installation will serve: Residence )g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/--- Number of bedrooms 3i Number of baths --- __ Lot size .__._._ ` t , � x- el-- ------------- ater Supply: Public system ❑ Community system ❑ Private jjL_Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Lam ❑ Clay ❑ Adobell, Hardpan ❑ Previous Application Made: Yes ❑ No)?j New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) epti T : • Distance from nearest well________________Distance from foundation---------- ----------�[JY� No. of compartments--- - --- Material -- ------- ---------._Size-------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest weIL�J� - -Distance from foundation.--Z to nearest lot line___5 Number of lines.__.___._. Length of each line____-_,?- j:� -- g . - .. Width of trench .V------------------- + . Type or' filter material._ [1-_---_k-__Depth of filter material __ ----Total length.____ ,,, : -_-•................... V Seepage Pit: Distance to nearest well _._- _- _ _ ___Distance from foundation___-__ --._-__-.Distance to nearest lot line..... ......... ❑ Number of pits.- ----- -- --Lining material--------•--------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well----------------- from foundation----------.---------Lining material-__-____-__-_-___-_ ❑ Size: Diameter-------------------------------------Depth-------•--------•----------------------------------Liquid Capacity..--------------------------------- -------gals. Privy: Distance from nearest well-__-_--_--___-__---------------- _----------Distance from nearest building ❑ Distance to nearest lot Remodeling and/or repairing (describe):.---------------------------------------• --------•--- ----------- ---•---------------------•--------------------------------------------------------------------•---•----------------•---------------------------------•------------- ------- 1 hereby certify t a ave prepared this lication and that the work will be done in accordance with San Joaquin County ordinances, State law and les and egulati ns of the San Joaquin Local Health District. (Signed) r C tractor) By: - Tale (Plot plan, showing size of lot, location of system in re do wells, buildin etc., can be p aced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------- DATE__. REVIEWED BY------------------ ------------ -------------------- ------- ----------------------------------------------------- DATE-- BUILDING PERMIT ISSUED--------------- --I�--,_•------•--------------------------------------- ------------------•--------------------------------------- DATE------- - Alterations and/or recommendations______________ --•----- -------------------------------------- ------------------------------------------------------- ------------ FINAL INSPECTION BY____________ -----(�/ -- ----------------------------- Date----------��-J ---�-�--------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 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