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- APPLICATION FOR SANITATION PERMIT I'ermit .." 'No. + (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. =' This application is made in compliance with County Ordina e No. 549. ' lJOB ADDRESS AND LOCATION---- / •3 -----------------------'111,10--- -------------•---------------------------------------------- Owner's Name---------- •` .. Phone, �`�F4 3- - •--• ------- - - rAr"et Address �7_ - -------- -- --- - •------------------------------------------------------ - ---------=-------- / ,, p� Contractor's Name �• 0-" "� _ �'----- — ----- ---•-- Phone_':; ------------- Installation will serve: 'Residence Apa menet House ❑ Commercial E] Trailer Court [Motel ❑ Other E]Number of living units: --/-"__ um er of bedrooms ---------Number of baths _9_ Lot.size ________________________________._-_____________-__------__ Water Supply: Public system P ommunity system .❑ Privafe ❑ Depth to Water;fable k` Character of soil to a de th of 3 feet: Sand Gravel Sand Loam Clay Loam Clay Adobe Hard an p ❑ ❑ Y ❑ Y ❑� Y ❑ (� p ❑ Previous Application Made: Yes ❑ No New Co64ruction•:Yes=�o ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: . (No septic tank-or cesspool permitted if public sewer is available within 2QQ fet.) p r k r ( - . No. of compartments--------- Size------------------------- - -- -Liquid"�ep{ ------------ a - cit -e ti Tank: Distance from nearest well............. Distance �fronfdundation._...,_____t_--material h________".........__....__Ca Capacity ispos I Field: Distance from nearest weilDistance from foundation____________________Distance to nearest lot line-_- ----- Number of lines----------------------•------------Length of each,line_---------------------1___.,Wjdth,of trench----------------------------------- , ' 4 Type of filter material-------------------------Depth of filter material----- -------Tota! length-------------------.----------•--�____-- t_ �} G '} -----_.-Distance #o nearest lot line_-- _-.Z + e l See a e it 2 Distance of njtares wsil_,�DO fining material.,/ m foundSize..nDiameter.--- 8__��---.-_-.Depth------- p t Cesspool: Distance from nearest well-_._____- "_Distance from fo ndation ____--- -__.._Lining material________._____"__________________ ❑ Size: Diameter-----------=----- -- x .�'-- .y a '- ii . :Depth Liquid Capacity gals. Privy: Distance from nearest well------------------ ------------------------ ----Dista ce fro nearest building.---------------------------------------- --- El Distance to nearest lot line----------------------------- ' i_ Remodeling and/or repairing (describe)_: ------------------------------------- ----------------- ------ - = - --------------------------- =" 4 r ------------------------------------------------------------------ ._. ¢___---_-"_.________... _.._""_______--__-"_"�______ ___-_-.-_--..____________-------- - �_____________________•___-�-- -------------------_------------.------------------------------------...................-_______'______--"__-_______--_-.-- .-.-__________----____----I----------------------._..A-.].-"_________"-___"-___________-_. I -------------------------------------- --------------•---------------------------------------------------- k ------------------- .,- I hereby certify that I have prepared this application and-that the work will be done in accordanceW,,San Joaquin County ordinances, State laws,, and rules and regulations of the San Joaquin otal Health District) f (Signed) -A ------- -------------- (O rand/or Contractor) 0/0 - = %� By:------------------(� :.. � - ---------------------� ------ -�`--- -AT-itle�- --- - - --- ----------------------------- . (Plot plan, showing size of lot, location of sys min relation to wells, buildings, etc-.i-.can be.placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY ---------- ------------------------------------------------------------------ DATt1�-----------= ----------------------- REVIEWED BY = ----- ---- ---- DATE rte"'---------------------- -------- ----•-------- BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------.. DATE- ----- --------------------------------- Alterations and/or recommendations----------=---------- - ------------------ •------------------•----------------------------•--•----•-----------------. s ------------------------------------------------------------ ------ ----- ------------------------------•----•------------------------------- ---••-- ---------------------•-------------------:----------------•-------- FINAL`INSPECTION BY:. "- 'A Date ---------------- -- ------------- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfreet 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M ; Revised W-2100