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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued 2 so �J 'Applica-lion is hereby made to the San Joaquin Local Heal t�h` District for a permit to consfru O�S`— -pi-.and install the.work herein described. This application is made in compliance with County Ordinance No.-549. JOB ADDRESS AND LOCATION .__ g` 7 D,__' Owner's Names = -�-----------•---------------------------- - ---------------- -------- Address..... -----._Address----- .............'2.... n`' r 'Q = ---------------------- C -------------------f-J------/---`---s---G----.-�-.- ----- Contractor's Name---------------------- Phone .17� Installation will serve: Residence ; Apartment House ❑ Commercial F] Trailer Trailer Court � Motel Other El Number of living units: _I_ Number of bedrooms Number of baths _-Z Lot site ._ a��/__ ------3. _7___ ---------------- Water Supply: Public system ❑ tCcm44ty system ❑�Private [r6epth to Water'Table 3S ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ No [l--1.New Construction: Yes �o ❑ 4 TYPE OF INSTALLATION AND 5IPECIFICATIONS:T {No septic tank or-cesspool'Perm iff ed if public sewer is available within 200 fee � f ' Septic T nk: Distance from nearest well I0;? Distance from four dation_f ' Matey I _ '-- ----•----. No. of compa�ments._._..-9--------------Size.--•- ---X � _�.Iiquid depth----- --;-t -------Capacity_-�_a_V49----- j. Disposal Feld: Distance from(nearest well,/d..-_.._Distance from foundation____�d-_-_,----"Distance to nearest lot line__/A_-____-_ Number of {ine's--------- ----------------------Length of each line--------7-1�-_--------------Width of trench-----�Fy_1'_----_.---------••- Type of filter material__S�_ _Pelf___Depth of filter material-__�$_IV.:,__.___TotAl length------ s-�___-________________ I Seepage Distance to nearest well-Aa---.-------Distance fromjfoundation___.3.d._...__.Distance to nearest lot line_ JQ-�___ Number of pi s-----f--------------Lining material�u�-e►.r" --Size: Diameter_-- - ----------- -----------------• Cesspool: Distance fromnearest well-------------- from foundation--------------------Lining material------------------------------------. ! ❑ Size: Diameterw----------------"-------------------=Depth--------------------------------- ------------------Liglid Capacity---------------------------gals ! Privy: ` Distance fromnearest well-------------------------------------------------Distance from neareslbuilding----------------------------------------- ❑. Distance to nearest lot line------------------____--------------------------------------------------------------- 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, Sta a laws, and rules and regulations of the San Joaquin Local Health District. `: h - --------------------------------------j___ y (Signed)------ ----- ,-yam -� ---------------------------------------------------- ------ ---- ----------- {Owne�and/or Contractor) By:-------- !!`�t- ---.. ----------------------------------- ----{Title} (Plot plan, showing size of lot, location of syste in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------------------------------------- �' ------------------------------- DATE------------------ - REVIEWED BY---------------------------------- DATE ---------- - BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------•------------- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------------------------•------------- --------- ------------------------------------------------------------------------------------- ----------- ---------------------------------------------------------------------------------------------------------------- -------•---------------------------------------------------------------------------------------------------------------------•-------------------------------------------------------•-------------------•-------------------- '* -----------=---_- ------------------------ -------- FINAL INSPECTION BY-------------------------------- ------- Date M 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 Revised W-2100