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APPLICATION FOR SANITATION PERMIT Permit No. ._. ..__ y�1 (Complete in[ p 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. his application is made in compliance with CountX Ordinance No. 549.. JOB ADDRESS AND LOCATION __ __ ._- - 2Id�, Owner's Name_-._-_ _ _ � � ------------------------------------------ ------------- Phone Address----------- zo `- - --- -- --• -`-`ems-- Contractor's Name____ " •-------- � -----•-•-- ..... Installation will serve: Residence Apartment House E] Commercial ❑ Trailer Court ❑ Motel [3 Other ❑ Number of living units: _ -- Number of bedrooms /___ Number of baths ---f Lot size Water Supply: Pubiic system ® Community system p Private ❑ Depth to Water Table _y0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe® Hardpan ❑ Previous Application Made: Yes ❑ No 12 New Construction: Yes 21 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weli_A4-441115istance from foundafion__/��/-----_-..Ma No. of compartments_,.--_oZ-- ------------Size_-_s6"�C�/o-~XS''--Liquid depth... ---7_ -- ---_Ca aci a n � Disposal Field: Distance from nearest eIINO_N�{I Distance from foundation_-__ v - ___.Distance to nearest lot hneS__.. 0 rZ Number of lines---•------ ---------------- Length of each line-----,e--d P--------------.Width of trench--------F_.V --------------------- YP r Et -��=_ Depth of frlter material---Lg_'�. d/ ---- -Total lengfh-------p --------------------- 5eepage Pit: Distanoce toenearestr'well.___._.--_ Disiance from foundation____________________Distance to nearest lot line-----------•- -- ❑ Number of pits----------------------Lining material---------------- _.__ - - --Size: Diameter------•----- ------ --Depth--------------------------------- Cesspool: Distance from nearest well________,F.------Distance from foundation--------------------Lining material------------------------------------- Size: Diameter---------------------- -------------- Depth------------------4------------ --------- -----Liquid Capacity _gals. .« Privy: Distance from nearest well_________________________________-----------_ Distance from nearest building ❑ Distance to nearest lot line______.__;____..__________________________ ------------- Remodeling and/or repairing (describe)-------------- f______ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ -•--------------- > ...------'-------•----------••----------------"-------------•---------------------------------•-------- ------------------------------------------------------------•------------------------ I hereby certify that I have prepared this appf lication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and andel regulations of,theSan Joaquin Local Health District. .... .... -------- -----------P---(Own4rand/or nfrac�orJ - - -� ------------ ---------- ------------(Title)- (Plot plan, showing size of lot, location of tem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY f APPLICATION ACCEPTED BY__, -�` ` ' CC� �s �------------------------------ DATE----- --- ----- REVIEWED BY ------------ -- -----------------------•--- ---------- ------------------- DATE------ BUILDING PERMIT ISSUED-------------•--------------- - ------------------------------------------ --------------------------- DATE.--- �------------------------- - -- Alterations and/or recommendations:--------------------- --------------------------------- ._ _ --- --------- --------------------------D..------- FINAL INSPECTION BY........... ------•--------- ---------- - -•-----------•- -- ate---- •--------� 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 : Revised W-2100