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APPLICATION FOR SANITATION PERMIT Permit,No. (Complete in Duplicate) Date Issued - -x_61-1s x- Applica{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. ------------------------------------------------------------------------ JOB ADDRESS AN ZI......... -------- ,��CATI Owner's Name- 04--------- - - ------------------------------------------------------------------------ Phone.---- ---------- -------------- Address- --------------------------------------------------- ---------I------------------I--------------------------- - - --- ------------ --- - Conf 1a'cior-s-Name- --------------------------------------------------------------------- Phone_; __, -------- Installation will serve: ResidenceA Apartment House E] Commercial E] Trailer Court [] Motel C] Other ❑ Number of living units: --- --- Number of bedrooms fg--.,Number of baths ,1--- Lot size _________________________-_ Water Supply: Public,systemA Community system Ej Private [-] Depth to Water table,�_�ft: Character of soil to .a depth of 3 feet: Sand E] Gravel [] Sandy Loam 0 Clay Loam ❑ Clay E] Adobe " Hardpan ❑ Previous Application'Made: Yes F] N OX New Construction: Ye 514 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1'(ffo-septic tank or cesspo-01'permired if-public sewer is available within 200 feet.)- Septic Tank: Distance from nearest well________________Distance from foundation---------------------Material---------------------------------------- ------- N06. of compartments--------------------------Size---- -----------------------Liquid dep'tk------------------------- Capacity----------------------- Disposal Id: Distance from nearest well------------- ...Distance from fotindation-------------t__6istance tc�`nearesf lot line_.__________.._-- ❑ Num'ber,ol lines-----------------------------------Length of each line------------------------I____.Wic1fh,oi trench.--------------------. -' ------•--- k Type rench------------------------------- Type of filter material-------------------------Depth of fialaLmaterial----------------- ___-_Total length_______________________.--__.._._______.__ Seepa e Pi Distance to nearest well,,.-.�_ -----------Dis nce from f indation--..,,,��.-�.---.Disfance to nearest lot line______ �Iumber of pits-------/-------------Lining ma erial&_ ------ - --- ---Size:Size: biameter--------7 Dept h........1;6--------------- cesspool: Distance from nearest weld_________________ ;stance from undaf-ion- -1--------- ------ Lining material___-_______________-__________-_____ Ej Size-, Diame�er---------------------------- ---------D A-------- ----------------------------------- ----Liquid Capacity............:__--------gals. I I "I Privy: D;stance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line------------------------------------------------------------------------------------------ ---------- - ------------------- I - oe f -1.,- � x, Remo e and/or re air' tribe :---- - -------0- ----------------------- ------------ n I - - -- -- - ------------------------------ -- ----------- --- -------- ------------------------------------------------------------------------------------- --------------------- ------------------------- -------------- - -------------------------------- --------- ------------ --------------------- ---------------------------------------------------------------------------------------------------------------------- -••---------=-------------------------------- -------------- ---------1--hereby certify'.that hey.e pre.pared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, anqrrules and regulations of the San Joaquin Local Health District. (Signed)------ -------------------------------------------------------------------------------- (Owner and/or Contractor) . - -!----------- `- By:------ ------------- -------------------------------------------------------------------------- --—----- ------------------- (Plot plan, showing,size o lot, of system in relation to wells, buildings, etc., can be placed on reverse sis e). Yi FOR DEPARTMENT USE ONLY 'APPLICATION ACCEPTED-,By_.,?'--------------------------------- - ----- ---- ---------------------------------------- DATE------L------- __C -- ----- -- °-'REVIEWED BY-----------------------" ------------------ -------------------------------------- ---------------------------------------- DATE----- --•--------------------------••-•--', BUILDING PERMIT ISSUED.-------I--. -- ---------------------------------- DATE------'------------------------------- ------------------ --- -------- ---------------------- ---- Alterations and/or recommendations; ------------ ----- --- ----------------- ---------- ------- !;Z� /J., N_� ----------------- ------------- I--- ------------------------- - ------------------------------------- ---------------------- ------ --- -- --- - --- - -- ------------------- --- -------------- ----------------------------------- - ------------- ------------------------ ------ ------ ..................................... ------- -------- --- ------------------- . .... - ---------------- --- -------n;�---------------- ---------------------------------------------------- -------------------------------- -- ---------------- ---------- --------------- -------------------------- FINAL INSPECT-ION BY:_ Date----------b-71-1----- --- --------------------------------------- ------------- - .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 E5-9-2M Revised W2100