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S APPLICATION FOR SANITATION PERMIT Permit No4.......b I 7 l (Complete in Duplicate) ,✓ '7 Date Issued __ -- --- V 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 o. 549. JOB ADDRESS AND LOCATION---/4?-- -- ---------------- - -•------------------ ..._._.... ------ -- Owner's Name ----------------------------- ------------ Phone Address___. Contractor's Name------ ___� -►G� ---------------------------------------------- Phone_�'�_ .__d_ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _t-____ Number of bedrooms Z. Number of baths --:- Lot size ------ �____. �_4 --- ------------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobW Hardpan ❑ Previous Application Made: Yes ❑ Nor New Construction: Yes}� No 171TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic-Tank: Distance from nearest well-- --Distace from foundation_____-----------Mat ._.-___---___-.____--- ---- ___. No. of compartments-.-______ _________Size__j_)0(ZX-�------ ,___Liquid depth.... �-------._Ca acit Disposal Field: Distance from nearest well-----------------Distance from foundation---_ .-___---.Distance to nearest lot line-a7sf__-_ \' i Number of lines______________-/_____.___ ___ Length of each line_____!__.��____.Width of trench._______V-__�--_----------- Type or filter material.C_t_ _ Depth of filter material___.-/...___.__._Total length______r __d_11_----------------------- Seep? e Pit: Distance to nearest well----------------------Distance' from foundation-_4177P.."__.Distance to nearest lot line_A2_r__r-.__ Number of pits-------/---------Lining material Size: Diameter-----3-4-----------.Depth__..A- -------------------- ' J Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material__________.______.________________ ❑ Size: Diameter--------------- -----Depth---------------------------------------.-------------Liquid Capacity--------- •---------------gals. Privy: Distance from nearest well---------------------------------------.---------Distance from nearest building-____-_______.________________.___..___--- ❑ Distance to nearest lot line- --- ------------ --------------------------------------------------- ------------------------------ ----------------------- ---------------- Remodeling and/or repairing ----------- 1117=---------------------------------------------- --------------------------:----------------------- --------------------------------------------------------------------- ----------------- - -----------••----------------------------------------------------------------------•-----••---------------------------•-----------•------------------------------------ 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 Health District. (Signed) .______ wner and/or Contractor By:------------------------------ �� = (Title) -f' (Plot plan, showing size of lot, location of system in ation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- ---------------------------- ------ ---------------------------------------- DATZ=7r-------- - ----------------------------== �' _ ------ DATE--- - - --- - REVIEWED BY ---------------------------------------- BUILDING PERMIT ISSUED------------------------------•----------------------------------------------------------------------- DATE-- -------------------------------- Alterations and/or recommendations------------------------------------- - ---•----------------------------------------------------- -----• --- p---------------------------------------------- / --------•----------------------.------------ ' /------ ?r .rl(t I --- -- '� ; °E'• "' -�. Ne r 1t---------•--- .� I -------------------•------------------------------------------------------------------------- ---------------------------------------------- -- ---- --- FINAL INSPECTION BY---------------------------V-- 1Z� G' -- ------ Date--------------- ---------5 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 , i ES-9-2M 0-52 Revised W-2100