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, r APPLICATION FOR SANITATION PERMIT Permit No_ (Complete in Duplicate) �• Date Issued ________ ________ Applica+ion is hereby made to the San Joaquin Local Health District for a permit to constr4ainstall the work herein described.This a'Pplicatibn is made in compliance with County Ordin ce No. 549JOB ADDRESS AND O ON-- � � �- - Owner's Name �,�/ ----- ------------------------------------- Phone__ Address -------------------------------------------- ----------------------- Contractor's Name `-� � , '�- ------------ Phone_ � -0- �' �� - wj Installation will serve: Residence ❑ Apartment House ❑ Commercia Trailer Court ❑ -Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths_ Lot size ____l D�_� O------- Water Supply: Public!system Community system ❑ 'Private ❑ Depth to Water Table ff. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam El Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes'❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool perrPiff ed if public er is available within 200 feet.) ��,pv Sep is Tank: Distance from nearesr well- ________Distance from found jjtion_ _d i Material--- ----- ----_ ,,��---------.-- f No. of compartments- - . --„-----�Yx_tiq d depth �fCapacity-/.d�'0 ______._Size --------- �•r-----Disfiance to nearest lot nce (Distance from Disposal Field: Numaber ofolines----- welf_� Length of each line---atio�� Width oftrench..zA4_�/___________________ Y Type of filter material.-_-� +r2 -Depth of filter material__.-1,��`---____Total length--:----- °� ____________________ l See a e'Pit: Distance to nearest rvell '1F - __.:__Distance fro foundation__._________.D' ece to nearest lot line_--___ -_____Number of is Lining material-C ::.Size: Diameter ---- Depth_ r"•------------- p 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 =------- '--------==--=------------•---- ---------------=--------------------- Jelin d/or repairR b -- �_ -------------------- '--- =-- _ ----------- J ___________________________Y ___ _ _ _ ____ _ __ _ _ I hereby certify.thaf.l hav prepared + supplication and that the work will be done in accordance with San Joaq in Coun ordinances, laws; and.r yes a regulations of theJoaquin Local Health District. ` 5 ( Contractor) (Signed.)------ - - ---- ----------- :. ------- ---- ------ ---------(Title)- By �'_ /.� (Plot pian, showing size of lot, location of system in r wells, buildings, c., can be placed on reverse side). FOR DEPARTMENT USE ONLY IAPPLICATION ACCEPTED BY: � -------- ------ - ------------------ ----------------- - ----------------------- --- - DATE_ -.�-.----------------------------------------- -------- REVIEWED BY ----- --- -- ` ---------------------------------•------ DATE . _ BUILDINGPERMIT ISSUED------------------ '---------------- ------------------------------------------------------------ DATE---------- :�--------------------------------...._,------- Alterations and/or recommendations: -------------------------------- -- --- -----------Z --=------------ °•=..----------- ---------_--------- ----------- ----•----_------------- -- .I Lre+�R'i1`"'r'1 e"�_-' _ .!I:+-- „"7!-`�P-'�----- �. xi4-------F1y .-? r ._r�%�=,A. :':'. -------- __,'�-- -pl ............r+ y. � ------ � i- - -------- - -- - -- - r- -- --------- ----------- ----- ---- -----------•-----------•---•----------- x ______________________________________ ___ ___________________- __...--.___.___.________._.__-.._________._._.____________. FINAL INSPECTION BY:.___ .. =-- -' -” � -------------- Date ------------------------- 1! 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