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�a 'APPLICATION FOR SANITATION PER Permit Nil ---- 5- (Complete in Duplicate) 7 w _ Date Issued .--- Z71 Applica+ion is hereby made fo fhe San Joaquin Local Health District for a permit to construct and install the work herein described, This application is made in compliance with County Ordinance No. 549. I JOB ADDRESS AND LOCATI N__________ ------- - Owner's Name--- -------------- - Ph on----------------------- on ------------- Address --------------- Contractor's Name-----{----_-- - t -1----------------- ---- - ---------- - - -----�--- -- -- ----- _ Phone. Installation will serve: Residence t14 partment House ❑ "Commercial'o-CoC u t; ❑ Motel ❑ Other ❑ Number of living units: -_ Number of bedrooms - Number of baths __-� Lot size - �s ri�. . � - ------------------------- Water Supply: Public system ❑ Community system ❑ Private �Uepth toWaterTable Character of soil to a depth of 3 feet: -Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [I Clay ❑ Adobe 0--i9erdpan ❑ Previous Application Made: Yes (] No �ew Construction: Yes ❑ No ❑� TYPE OF INSTALLATION AND SPECIFICATIONS: + . (No septic fank`or cesspool`permiffed if public sewer is available within 200 feet.) Septic Tank- Distance from nearesr well----------------•Distance from foundation-----------1--------Material--- ---------------------------------------------- No of compartments---- - 1 -----Size--------------------------------Liquid depth-------------- -Capacity Disposal ield:V Distance from nearest well---:�------Distance from foundation___3a--- .- Distance to nearest lot line--_'y - ---- --Number of lines------ -------`------------------Length of each line-------Y5_`_--�-------:Width of trench_ _� " Type of-filter material--- t-J�o-L- .. ,� 5-/ t�---------------------- - _._Depth of filter material 1-g ----_--_Tota! length-____7 __.__-__ — rt , I. ! a . > -- -------- Seepag Distance to nearesf" eii_`,/Q-Q--- ='Distant om oundafion----________________Distance to nearest lot line-".ya-.l--_ Number of pits_ ._ -------------Lining material_' _-- '� Size: Diameter_:--_---- ----------Depfk_v?s--------- Cesspool: Distance from nearest well_________________Distanceifrom foundation.__-_._.__.__---"- Lining material------------------------------------- El 5;ze: Diameter€ ------ Depth------------------------------------------- ------- Liquid Capacity----------------------------gals. Privy:' Distance from lnearest welL_e_� :)_-__---._: Distance from nearest building I .. i i g------------------------------------------ ❑ Dfsfance•to nearest lot line _______ 1 --------------------`-- ------------ Remodeling and/or repairing fdesc b6j-.__'--______________ _________ _ t { R -------•------•----•---- - - -------------•-----•------ i . + . -- --•----••-------•--•-•-----••------------•------•---•'---------------------•---•--------------•--------------------- t i } k I hereby certify that I have prepared this application and'fhat the work will be done in accordance with San Joaquin County ordinances, State laws;and rule a diregulations of the n Joaquin Local Health District. (Signed) # =-------------------------------------------- / , weer and/or Contractor) By: ------------------ ----------• I (Title)= A W-1 r -•---- Plot tan, showingsize of lot, location of sysfe m relation to wells, buildings, etc., can be placed on reverse side). j . FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY___. ._- ------ ------------------------------ DATE----------------•-------- BUILD NG PERMIT ISSUED------_-.•---------------------------�-�--------------------- .i- --"."-----DATE ------ --------••------------• -_- DATE Alterations and/or recommend ,Mons:------- r ------------------------------ ---------------------------------_ _ ------------- -------------------- 7- -- ---- f I: - ------------- -----•------------•- "-- -------- ----- ----------- FINAL INSPECTION BY:.--=- -- ------- -- - - ----------------------- Date__,,�- -- -".- SAN JOAQUIN LOCAL HEALTH DISTRICT 7 130 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-21oo