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APPLICATION FOR SANITATION PERMIT e It 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 herete'scribe3d This application is made in compliance with County Ordinance No 549 JOB ADDRESS AND LOCATION------ ----�- --- ---- ---fir- - j !� ----------------- -------------- Owner's Name--------------------- ---------- Phone------------------------------------ Address.......................... -- - ---- --- ------- - --------- --------------------- -- ------- ---- -------- ---------- Phone.._�__._��_ Contractor's Name------ lr'd7ed- �v Installation will serve: Residence Apartment House E] Commercial E] Trailer Court E] Motel' F] Other E] Number of living units: er of bedrooms _Z_ Number of baths /---- Lot size — ----------------- Water Supply: Public system 40010Community system E] Private Ej Depth to Water Tableff. erQ--- Character of soil to a depth of 3 feet: Sand E],,,Gravel [j Sandy Loam ❑ lay Loam El Clay I-] Adobe 9--Hardpan E] Previous Application Made: Yes E] IN 0 New Construction: Yes e No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Distance from nearest well_________________Distance from foundation______________-----Material____--_______---.___..._----------------------- m 0 ��I; No. of copartments--------------------------Size--------------------------------Liquid dep.fh--.------------- -------- Capacity------------------- --- Disposal Field: Distance from nearest well________________Distance from foundation--------------------Distance to nearest lot line______-----__-___ 04�� ` , / . Number of lines-----------------------------------Length of each line--------------------- --------Width of trench-.--------------------------------- '7/' Type of filter material-------- ----------- pth of filter material-----------------------Total length_______.__________..______-.-------------- Seepage,Pit: Distance to nearest wellA f rom �ounAf ion--Z-! _________.D'/d) --Distance D' t ce to nearest lot line-- ----._/---- Number of pifs._,� ------Lining material___,.6ZAoZc40F',Site: Diameter--j--------------Depth---- '' ' Cesspool: epth----- Cesspool: Distance from nearest well-___-_____---__Distance from foundation.._._.____________.Lining material___.___-_____. ❑ aterial---------------El Size: Diameter---------------------------------- ---De pth--------------------------------------------- - ----Liquid Capacity----------------------------gals, Privy- Distance from nearest well-------------------------------------------------Distance from nearest building----------I------------------------------- 11 Distance to nearest lot line--------------------------- -- ------------- ------------------------ Remodeling and/or repairing (describe)----------- -------- -- - -- ------------------------------ ------- -------------------------------------------------------------------- ----------------------4--------- ---t--------------- -- -- --- -------------- ------------------------- ------------------------- d -------------------------------------------------------------------- ...... _. ------- ------- ----------------------------------------- ------------------------- ------- --------- ------------------- ------------------------------------- ---------------------------- ------ -------------------- ---------------------------------------- ---------------------------------------- application and fha the work will be one in accordance with San Joaquin County I hereby certify that I have prepar d ;�is ordinances, State aws and rules an eg _.pbrula of th an Joaquin Local H alfh District. .. ---------- -------�� ,�Ow�nand/or �nfi . ........... (Signed)------- ...... A ___ _14 --1�,_Z. Own and/or nfracfor) 46 By:---,, - --- -----------------------------------------------------------------------------(Title)--- - -- - --- -- ---- ------------- ----------- (Plot plan, showing size-of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED By DATE. e------------------------------------------------------ REVIEWED BY-------------------------------- ----- I JNIN_�_ DATE 10;----------------------------------------------- BUILDING PERMIT ISSUED___------ - ------------------------------------------------------------------------- DATE-----------V Alterations and/or recommendafions:----------------------------------------------------------------------------- --------------------------------------------------------------------------------- _1--------------------------------- ------------------------------------------ ------------------------------------------------------------------------------------------------ ------------------------ - ----------------------------------------------------------------- ----------------------------------------------------------------------------------------------..............._-_--------- ----------------------------- ---------------------------------------------------------------------------- -------------------------------------------------------------------- -------------------------------- ------------------------------------------ ------------------------------------ ---------------------- ------------------------------------------------------------------- ---------------------------------------------------------------------------------------------- Y-k*C-j ti-j- FINAL INSPECTION BY----------------------------------------------------------------- Dafe------------ 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 10-52 Revised W-2100