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APPLICATION FOR SANITATION PERMIT Permit No.�_0 - ! _____ (Complete in Duplicate) T Date Issued �—..�. .w.. ;��. ��- �•�'tri a*- -t:' �S i - ,� .. .. -� _ _ ... - Applica-l-ion 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 Ordinance No. 549. f JOB ADDRESS AND LO �TIO --- -7_. •`�Owner's Name-----=-------` ,: hon- -- Address------------------------ a«t• . 3 �,�. -----------f---'----•--------------- Contractor's Name------------- ---mss_ __rse ----- ---------:--------- -- ---------------------•-------------,-------- Phone--'----- 01 --------�- --------- Installation will serve: Residence ff__Apartmen¢House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Wate�Number of living units: ♦gI_f _Number of bedrooms :J-Number of baths._1__ Lot-size _-1�___s�__ �______- _ -- - - Supply:' Public;system �Community system ❑ Private ❑ Depth to Water Table .41d ft. Character of soil to a-depfh•of 3 feet: !Sand Gravel ❑ Sandy Loam E] Clay Loam ElClay E] Adobe eHardpanEl Previous Application Made: Yes E] No ew Constructi n: es No [ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septid fen kfor`cesspool'p(.-rrriitted if public sewer is available within 200 feet.) Septic Tank: Distance-from nearest well-_'-..------------Distance=from foundation--------------------Material-_____._____ .____._--___ ______________. ❑ ' No. of-compar#ments----- -----.- Size----••--�•---= --`----------Liquid depth---------------------------Capacity ---------------------- __ Disposal Field: Distance from nearest well_, -_ -.--__._Distance from foundation_____-.Distance to nearest lot line__ ❑ ' Number of line's---={---f_'----------------------Length of each line-----------------------------.Width of trench----------------------------------- T ----------•----------------------- Talu ype of filter material-_- *°``______________Depth of filter material----------------------- length_-_----__________--_-________-,_--------- Seepage _--.- „� p ; i See a e„Pit: _ Distance to nearest.well '�,C--________Distance fr m' tian_:_3• _ 'p 9 �___._..Distance to nearest lo#.___.Linin material_c_____ A�oun ze;'Diameter_-__ -_ Dept n [� Number of pits = g e - p Cesspool: Distance from nearest well-----------------Distance from foundation--------------- -_,Lining material---------------------------______-___. ❑ --------------------------------- - f - Capacity -----------------gals. Size: Diameter_ --r De th______ �_Liquicl Ca Privy.i Distance from.hearest well �� --_- ____ ._Distance' from nearest building ------------------------- -Distance --- `–'Distance to-nearestlot!line--------�'----:°--- - - �f = --------------------------- and/or repairing (describe):----------- ------------ -------------------••-------------------••----------------4----------•--------- - -` ------- -------- ----------------------- ------- •----------------------------------•------------------------_------•---..-----------------------:---------•------•-----------•------....._..••------=•--•----------------------•------•--........------- ------= -------- y 1 hereby certify that I have prepared this application'and that the work will-be done in accordance with San Joaquin County ordinances, State laws and rules and regulations of the San Joaquin Local Health District. Si ned � Contractor) 9 B-------•---= - ----- • -----.-- `------ --'--------- f ---------------------- -------------------------------------Ti ----=----=--------°-�- ----•---and/or on -ac+or) ------------------------------ r----------� - { +lel ----------- s (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). # r _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY '-------------------• u ------------- — DATE--------- REVIEWED BY-----------f------------;' === = ",: ”__:__: :DATE.. s t ---------- BUILDING PERMIT ------------------------' •------------ == -. DATE ---------- AlterAlterations ations and/or recommendations:----I------- ------------------------------------•---------------------------------- ------=--------------------------------------------------- ------------------------------- -------------------------------- -------------------- ------------------------------------------ --------- ----------- ----•---------- ---------------•---------------------•--------•------ ------------------------------------------------------------------------------------ --------------------- -------------------------------------- ---------------------------- ----------- -----------------•-----------=--------------------------- --------a------------------------------------------------------------------------------- ----------- ------- �:f� �. _ ..._ FINAL INSPECTION-BY: _ -�7t-- ----_----:--" Date------_-- --- --:- ---- ' 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-2104