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APPLICATION FOR SANITATION PERMIT Permit No. + (Complete in Duplicate) Date Issued r Application is hereby made to the San Joaquin Local Health District for a permit to constructthwo r o&6 i described. This application is made in.:complian with Coun Ordinance No. 549 in JOB ADDRESS ND E,OC��• - -- Owner's N -------- -- - s� r ------------- - `T� ---------------- Phone�.`_� �-------- Address------- •--'--f-t--- - --- -----�_�-- -, --•------ - Contractor's Name------------------------------- --------------------------------------------------------------- ----------- Phone Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court ❑ Motel -� � ❑ Other �_- [�] Number of living units: __ __ Number of bedrooms 3--- Number f baths -1-___ Lot size __�- - ~ Water Supply: Public system ❑ Community system El Private Depth to Water Ta��Cl_ay Character of soil to adepth of 3 feet: Sand Gravel ❑ Sandy LoamClay Loam ❑ - Adobe[I Hardpan E]Previous Application Made: Yes E] No New Construction: Yes eNo ❑ TYPE OF INSTALLATION:AND}SPECIFICATIONS: (No septic tank or cesspool permitted if pubic sewer is available within 200 feet.) Septicanlc: Distance from nearest welf�Oa e fr fo nPJation_I -_ Mauer i No. of compartments_---------Z--,-------- ize_T.x K Li Liquid t __-• ----- - ------------------------------ --------------------- q 4P. Capacty 2 Dispos I Field: Distancetfrom nearest w Ir,,. l� •' yy�� 11 _.__Distance from foundation_ _ i Istance to nearest lot lirye d Number of lines_---------Q---,I .__------- Length of each line----------- --- ��t-------- . g � � -- ---.Width of trench------.�--- - T e of filter materia_ ------' -- - �l -------- Type j Depth of filter material----.__1_ ----------Total length______--1_f:-_---- Seepage Pit: Distance to nearest well-----__---------------Distance from foundation-------------------- to nearest lot line.._________-___.- ❑ Number of pits---l__________________Lining material ---Size: Diameter-----------------------Depth Distance from neares# weil_________________Distance from:foundation---------------------Lining material-------- --------------- 0 ------ ---- Size: Diameter---- •----------------------------Depth----------------------- -- -- Liquid Capacity -------gals. Privy: Distance from nearest well-_------,---_---------------- --------------- Distance from nearest building ❑ Distance to nearest lot line_______________________ Remodeling and/or repairing (describe):------------------------------------------------------------------------- ' �5 ----------_-----------_______--------------------------______----------------------------------------------------------------- -------------------------'------------------------------------------------------•-----------------------------------------------------------•---------------------------------------------•------------------------------- '"-- ___________________ ________________________________________________________________________________________________________________________________________________________________________________ __________________ I hereby certify that ! have prepared this application and that the work will be done in accordance with San Joaquin County V ordinances, State laws, and rules and`regulations of the San Joaquin Local Health District. �� (Signed)------ --00,64 //> (Owner and/or Contractor) -----------------••-------------------------- x= •----------------------------------------•---------------------------------------(Title)---------------------------------------------- ----------- ----- (Plot pl n, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). t FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- --------------------------------------------------------------------------------- - ------------ DAT - - REVIEWED BY-------------------------------- ------- - ------------------------ ----------------------------------------------------•-- � -- --------1- ------ -------------------------- BUILDING PERMIT ISSUED-------------- DATE_ - ----- --- ----------- --� ----•-----------•-- DAT - Alfe atio s an /or recommendation :- 1 -- -- - )----- ------------------------------ ......I---------- ----------------------------------------V --- •------ ------ - - ----------------------------------------------------------------- t � , FINAL INSPECTION BY:_ ----------------:#__------------------------------------------ Date----- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 1 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California ES-9-2M 10.52 Revised W-2100