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APPLICATION FOR SANITATION PERMIT a.�-(�O Permit No, ..__�e2 (Complete in Duplicate) Q Date Issued Application is hereby made to the Son Joaquin Local Health District for a permit to construct and install thework herein described. Application This a plication is made in compliance with County Ordinance No. 549. JOB A DRESS AND LOCATION_,_____�i,P -_""-IQ Owner's Namejj� / ----------------------- t` i r_ "'1-�---------- - Phone. `Address------•-----• - -- - A � _ ------------------------------------------------------------------ Contractor's Name �'�'�'s-t�2r..✓ ® ---------••------- -----------------------------------------------------•----•---------------------- Installation will serve: Residence Apartment House [❑ Commercial � Phone-------•----- ----•----•- ❑ Trailer Court ❑/ ofvT tel—0 Other ❑ Number of living units: J---- Number of bedrooms .Z--: Number of baths -Z--- Lot r Lot size :� --�-1_�d Water Supply: Publics stem t PPY� y �f`Community system ❑ Private ❑ Depth to Water Table\___ ft. - Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ® Clay Loam [] Clay ❑ Adobe❑ . Hardpan ❑ Previous Application Made: Yes ❑ No Now Construction: Yes UP/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 weiL_--W-_av-:=Distance from foundation_ -- R i �� Material_(_p-"�-�- ® No. of corn artments----- -""-- �' �( i p Size_ Liquid depth Capacity -1 Id; .. Distance from nearest weil____�------Distance from foundation-" D.f__ -_ ---i"" Disposal Fie Number of -_= D ce to nearest lot lin 41157 lines___-_ Length of each-line, �� ` �� of trench-__y2 __ _ Type of filter material,a� ,De th of filter material-"�.0 '" Total length---�A� Seepage Pit: Distance to nearest well---------------------- from foundation-------------------Distance to nearest lot line_______________"" ❑ Number of pits----------------------Lining 'material-----------------------Size- Diameter-- ---_ Cess ool: - ---"" p Distance from nearest well ________________Distance from foundation-_--_-__--_-_____ Lining material ❑ Size: Diameter. ------------------------ ------- --------------------------Depth _ �... - Liquid,.Capacity----- Privy: Distance from nearest yrell _ _ Distance from nearest buildin ❑ Distance to nearest lot line 9 Remodeling ------------------ and/or repairing (describe)--____-____-_----___-__ " 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 rti egulaons of the San Joaquin Local Health District. ` (Signed) i' � h s� -- ----------------------------------------------------------"_--(Owner and/or Contractor) --- - - --- -- By:-------------------------------------•------- Title =- (Plo#-plan.-showing size of lot,-location..af system-in relation to wells, buildings, etc., can..be-placed,onjeverse_side). ---------------------- FORD PARTMENT USE ONLY APPLICATION ACCEPTED BY---- - --." --- "" ` ------:------------------------ DATE-- REVIEWED BY------------------- - -------------- --- •----------- -------- DATE--------------------- BUlLDlNG PERMIT ISSUED--------•----------`'-------•"""-- ----------------- - ------ -------------------------------------•----------- --------- DATE-------- ------------.----- Alterations and/or recommendations:_______._--_"""-_--"-__"-_ -------------------------------- ------------------------- - ---------------------------- -- -------- -------f ------------- -------- - � -- -------------------- FINAL INSPECTION BY__ __________. .� " = ----=�------- - Date_ r / • --------------- 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