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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Z, ' Date Issued Z�_-- ---�57/ Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with Countyyy Ordin nce No�549. JOB ADDRESS A LOCATI , Owner's Name______ - -- --- Phone-13 - 71 Address__. ---- ---------•-------- ------------------------------ ----------------------------------------- ------------------------------------------------------------------- Contractor's Name - -- - ------------ --------- ----------------- ------------------------------------ Phone - - ---- - Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot eI pOther ❑ Number of living units- _��ommun I Number of bedrooms _.-Z Number of baths _f___ Lot size -------- --------------------------------------- Water Supply: Public,system . ity system.-E], ,.-Private ❑ ._Depth to Water-Table-__ ____.ft..,. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loam lay ❑ Adobe ❑ Hardpan ❑ 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.], Septic ank: Distance from nearest well_--___________Distance from oun o _ __ Mater __---- --------------- No. of compartments------------ ____--Size---- _-7�-- Liquid depth-----_-__- - - --------CapacitY----�� Disposal Field: Distance from nearest well_________ _ Distance from foundation__--__ _ t _ Distance to nearest lot lin - Number of lines--*----- __-- Length of each line------------------- -�----_.Width of trench-------- -- ,{ -------------- Type of filter materi C __ --- pppth of filter material--_----� ---- ---Total length------------ -- --" - --------- Seepage Pit: Distance to nearest well---------------___----Distance from foundation--------------------Distance to nearest lot line__________---____ ❑ Number of pits---------------------Lining material------- -------Size: Dameter-----------------------Depth--------------------------_-- i ---i Cesspool: Distance from nearest well_________________Distance from foundation---------_----------Lining material---_____________--_________.___-_-_ ❑ Size: Diameter-----=---------------------- ---------Depth----------------------------- --- ---------Li Liquid Capacity -------- - 9 ----------------------------gals. Privy: Distance from nearest well __________________________----_-Distance from nearest building ❑ Distance to nearest lot line-------- ------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe)--------------------- ------------------_------------------------ ---------------- ---------------------------------------------- _____________________________________________________ ________________________„_______________-________-__•_._____________________-______-_________________-___________-__-_________________________-______-_________-_.___- hereby certify that I have prepared this application and that the work_ will-be done in accordance with San Joaquin County ¢ ordinances, State laws, an�a7; lations of the San Joaquin Local Health District. (Signed]_dlQl_ _- --- --------=---- --------=-----------------------------------_ _ (Owner and/or Contractor) !'lot fan, showing size of lot, location A By: - " ----------------------------------------------- --------------------------------(Title)-------------- -------------------------------------------- P 9 of system in relation to wells, buildings, etc.; can,6e placed on reverse side). ..... - �.T� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ` --------- ----------------------------------------REVIEWED BY ------- DATE-_-1 ---------------------------------------------- - ----------------------------------------------------------------------------- DATE- BUILDING PERMIT ISSUED Alterations and/or recommendations:__:____ / .5 :+~- DA -- -------- _ /�.L, �� -- - � ` rat. c r�� ----- ------ � __ - � -.-.n - =--- -. C __� ' - - -� '? -�----------------------- , f -------------------------------------:--------------------------------------- - ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- ---------- r . FINAL INSPECTION BY:__ __V_- ---------------------------------------- Date------- C - SAN JOAQUIN LOCAL HEALTH DISTRICT k E. 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California l ES-9-2M 8-51 Revised W-2100