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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) is /SS' Data Issued Applica�ion is hereby made to the San Joaquin Local Health District for a permit to constr ct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA ------- "�' • - Owner's Name >f Phone ____ e 7W----- ---------------------------------- Address------------------------------------------••----- -------- ' Contractor's Name--------------------------- er . _x_ G ----------------------------------------- Phoner ¢ ---- Installation will serve: Residence 0 partment House ❑ Commercial L] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __/__ Number of bedrooms -_7�Number of baths __`.. Lot size r__t ._f__-_- - �~ Water Supply: Public system Ej Community system ❑ Private �epth to Water Table -------- ft. Character of soil to a depth of 3 fee+: Sand ❑ G-vel ❑ Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe �ardpan E] Previous Application Made: Yes [] No New Construction: Yes ❑ No ❑ / � � TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or cesspool Permitted if public sewer is available within 200 feet.] Se c Ta k: Distance from nearest wel{_________________Distance from foundation-------------------Material------------------------------------------------- No. of compartments-------------------- -----Size--------------------------------Liquid depth--------•-----------------Capacity----------------------- Disposal Distance from near st well.�0_'-__-.-Distance from foundation_-�a_'•___.Distance to nearest lot line-�-! Number of lines---7-------r__Tf_.-_ ___ Length of each line___, Q_!__--_-.-_.Width of trench�4r�'!_-_----_--___________ Type of filter material_1_405 Depth of filter material------It_`_�------Total length__47-7Q__'_______________--_-_-__ �e (n Pit: Distance to nearest well from foundation to nearest lot line___-__._______ (,�[ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter---- ---------Depth--------------------------------- r , Cesspool: Distance from nearest well-----------------Distance from found4fion------------------- Lining material___.____,___---_-.__.-_____________-_ ❑ Size: Diameter--------- -------- -------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well---_----------------------------_-----------------Distance from nearest building______-_--____________-_____------_------. ❑ Distance to nearest lot line----------------------------- ----------------------------------------- ------------------------------------------- Remodelingand/or repairing (describe)---------------------- ---------------------------------------_.---•-----••--•-------- --------------------------------------------- --•--- ------------ - -----------------------•----------------------------------_----•-----------------------------------------------------•------------------------- I ereby certify t at I have prepared s application and that the work will be done in accordance with San Joaquin County ordinances, State laws and rules nd regu�5 ns of the San Joaquin Local He Ith District. _-----'_ (Signed) '" �Q: . ---.---- - -----------Qa erg Contractor] ------------------------------- By ............. ------------------------------=------------- ------ --- •- = (Title -1 ------------=-------- (Plot plan, showing size of lot, location of sys+e in relation o wells, buildings, efti., can be I cad on reverse side). kW-DEOARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ------ ---------------- ---------------------------------------- DATE------ tet- REVIEWEDBY--------------------------------------- --- --- ------------------------- ------------------------------------------- DATE------------ --- PERMITISSUED--------------------------• -- -------------------------•-------------•-------------------------• DATE---•----------- ---- Alterations and/or recommendations_________________ •-------------------------- ------------ FINALINSPECTION BY:. s---------------------------------- Date----- -------------- -------------------------------------------------------- SAN -- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised W-2140