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nor - Permit No. '7`-"-<----- - APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued~--" { Application is hereby made to the Sen Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with CountysOrdin ce No. 549. QQ� JOB ADDRESS A LQCATIQ - "` Phone °t,. ------- ----- ---- ---------- 0Owner's Name________ _ ` + ` -----•------------------------•----•--- ...--------------" Address---------IL_ ] ; Contractor's Name____ ________ _•--•- - - - - ------ -"---"-"- - omial '-------------------------------------------------••-----.- _ - - Installation will serve: Residence Apartment House El Commercial ❑ Trailer Court El Motel Ll Other Number of living units: _ "" umber of bedrooms _�- Number of baths _3__ Lot size ______ __ Water Supply: Public system 1 Community system ❑ Private ❑ Depth t °Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ IJN 6 No I7 New Construction: Yes [!(No ❑ Previous Application Made: Yes ❑ - TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted 'f ublic sewer is available within 200 feet• 1 ,, f --"-----Mate i __. � from nearest well____�__,'�'?'�Distanc #rom foundbtion_____�_i a- Septic ank: Distance ____.Ca l No. of compartments c ------Size Liquid depth / -'Distance from foundation. --------Distance to nearest lot li _5.....IL Dispos Field: Distance from nearest we I____ V Width of trench_____.____C_ ._____"_______. IL Number of lines_______"" --------- =Length of each line__----- -- �€ __Total length--------" --^� -------- Type of filter in- - al Depth of filter material_______ _ Seepage Pit: Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line____-__________- ❑ Number of pits--------------- -----Lining material------ ----------------Size: Diameter-----------------.-----.Depth---------------------------------- -� ► Cesspool: Distance from nearest well"Distance from f�ndation___l_0_"------Lining materia{__________r__�"�"" �!_ ` Size: Diameter----_ ---- p Li uid Capacity_"_____ ? ----r----gals. : --------- ---------- � — �" - _Distance from nearest building privya Distance from nearest well______________________________________ ❑ Y-Distance to-nearest-lot-:line-------------------- - - _ Remodeling and/or repairing (describe)-------------------------------------------------------- ---------------------------------------------- C -------------------- --"------------"-•--•-----------•----------------------------------- ---------------------- i -------•------------- -------_--------------- ---------- --• -- - f I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, nd rules and regulations of the San Joaquin Local Health District. ----------------------------------------------------(Owner and/or Contractor) (Signed)------- ,� -- �'�- ---•- - --- Title By:---------------------------------------------------•-- be placed on reverse (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can side). FOR DEPARTMENT USE ONLY DATE--- APPLICATION ACCEPTED BY---- `C� DATE. "REVIEWED BY------------------------------------ ----------------•-------------------------------------- DATE--------------=----------- BUILDING PERMIT ISSUED. -------------------•---------•-----------------------------•- - ------------ Alterations and/or recommendations:----------------------------------------------------------------------------------------------------------------------------------------------- --------------------------- -------------------------I----------------------------------------------------------------- •------------------------------------------ -------•---------------- ------------ ------------- -----•----- - f FINAL INSPECTION BY:-------� " -- "------------------ Date ----t -----------•- SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street p Tracy. California Stockton, California Lodi, California Manteca, California ES-9-2M 8-51 Revised W-2100