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APPLICATION FOR SANITATION PERMIT / Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the 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. / 'J_�Q JOB ADDRESS AND LOCATI N________ _ d?__g-_�^-- --- -- - ------------------------------------------------------------------- Owner's Name---------- ------ - -------------------------- Phone------------------------------------ Address________�._._�__6_el ----------- Contractor's Name--_ ---- — '` -- -- - '�- -------------- Phone-/t'P!? ?__�-------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _____ mber of bedrooms / _(�`- - -- ------------------ ______ Number of baths _ ___-__ Lot size _______ � Water Supply: Public system Community system '❑ Private ❑ Depth to Water Table-1___ ft. Character of soil to a depth of 3 feet: Sand ravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe 1�ardpan ❑ [ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ �y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta k: Distance from nearest well istance f om foundation__,r -______._.Materia e -------------- ------------------------------- �qg -------Ca acct ----------- No. of compartments___rC._�______________Size____ ___X.�.��_-Liquic�'depth_____� � p city- Disposal Field: Distance from nearest well/1-101,Gfl.G/.Distance from foundatio -- --________.Distance to nearest [of iine-40__________- Number of lines___________ Length of each line______C__ ��______.Width of trench _____________________ Type of filter material ! p g �rDe th of filter material__�ly__________-Tota! len th___-_- -Z1________________-______ 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-----------------Distance from foundation--------------------Lining material_________._____________---..__-.__ ❑ Size: Diameter--------------------------------------Depth--------------------- ---------------------r-------Liquid Capacity----------------------------gals. -------Distance from nearest buiidin y'�'F`---------------- El - _r----- Privy: Distance from nearest well----------------------------- -------- 9-----------------------'------- -- - --- ❑ Distance to nearest lot line---------------------------------------------------------------wl-- - ------------------------------------------------------------------ 01 ,�/ Remodeling and/or repairing (describe)----------------- �� ----- - ---------------A- -----------•--------------------------------------------------------------------- ---- , -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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, regulations of the San Joaquin Local He th District. R -- - - -�----�--/---(5i ned) - - --- -- ---- r-� Ow er and Contractor) ----------------------------------------------- (Title)-- ------ =Br (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 011 D,EMRTMENT USE O , LY APPLICATION ACCEPTED BY----- = DATE i _.- REVIEWED BY. ---------- - --------------------------- DATE BUILDINGPERMIT ISSUED-------------------------------- --------------------------------------------------------------------- DATE---- •-------------------------------- Alterations and/or recommendationt------------- ------------- ------------------------•---------------------------------------------------------------------------------------•------_ ----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------•---- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- -------------------------- -------------------- ----- ------------------------------------------------------- ------------ ---------------------------------- FINAL INSPECTION BY: Date ------------------------------------------ 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 8-51 Revised W-2100