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APPLICATION FOR SANITATION PERMIT Permit No. ... - --ICI.... (Complete'in Duplicate) rT Date Issued ----_f__ ___�f_:•G. 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. �` 1114. �. -� ---------��---=----- - - -------- JOB ADDRESS AND LOCATION____-�_�i--- .---/.�-----------�.------- �-----�-------� �-=�-=- - •--�. SCli �� Owners Name-------------- --..... Pone. = Address------------ 1"r---------��---- -------------------- ----------------------------------------------------- ,e,-) Contractor's Name--------------------------------' �r�='-`----c-�^�------------------------------------------------•------•-•--------- ----•---- Phone-------------•-••-• i� Installation will serve: Residence partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ----/-- Number of bedrooms ---/__ Number of baths ---/__ Lot size ------l p,S----_--- -_____________ Water Supply: Public system R!rCommunity system ❑ Private ❑ Depth to Water Table ------ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes []"No ❑ 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------------------------------------------ Size--------------------------------Li Liquid depth------------------ ❑ No: of compartments ----------- q ------.Capacity----------------------- Disposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line_-__-_.__---___-- ; ❑ Number of lines-----------------------------------Length of each line---------------------------.._.Width of french------------------:---_. ------._ Type of filter material-------------------------Depth of filter mater.ial-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well____________ ____. ____Distance from foundation-_-_-.___.-. -. 9 _ __.Distance to nearest lot line____:.____-__. ❑ Number of pits----------------------Lining material-----------------------Size: Diameter.----------------------Dept h-- ----------------------------------- Cesspool: Distance from nearest yell___.�.�.___.Distance from foundation-----______________Lining material---_------- X`��__.�_._____.__" ( Size: Diameter-------- G--------- -----.----De th---------7--------------------------------------Liquid Capacity gals. Privy: Distance from nearest well-----'=------------------------------------_t---Distance from nearest building----------.__-_-_---_ -_ tip ❑ Distance to nearest lot line----------------- ----------------------------- -------------------------•-----------•-------------------------------------- ----------- O Remodelingand/or repairing (describe)--------- --------------------------------------------------------------------------•-•-- •-•---•------••----------------------------------------------- -------------------•------•----•---------------------------------- --•----------------------------------•------ ------•-••-•------------•--•----•-•------------------------------•--•---------------------------------- --------------------••-------------------------------•------------------------------------------------ -7---------------------------------------------------------------------------------------------------------- Allp - ---------------•-------------------------------------••------------------------------ --------E -------------------------------------------------------- I hereby certify that I have prepared this application and-tliet 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. (Signed) ► tl ?�►------ --------------- --- ------------------------------------------------------------------------(Owner and/or Contractor) By:................ •------------------------------------------------------------------ --------------------------------------- -----(Ti+le)----------------------------------------------------------- (Plot plan, showing size of lot, location of system in rela+ion•fo wells, buildings, etc., can be placed on reverse side). FORTDEPARTMENT-US E-0NL'Y' APPLICATION ACCEPTED BY--- --' ----- ---------------------------------------- ----- DATE----- 5~ '------------------------ - -- ------ - ----------REVIEWED BY--------_---------------------- - --`---=--y- --9------------------=-----_._ DATE------------ - - ---------------=------------------ BUILDWG PERMIT ISSUED------------ - -------------------------------------------------;-- DATE------------------------------------------------------------- Alterations and/or recommendations:------------------ w__:.=-------------•--••-4_-------=` === `---------•------• --------..------•-------------------------------------- ---•--•-•----------------------------------------------------------- ------------- - -----------------------------------------------------------.------------------------------------------------------------------------- ---------- ---------------------------- -------------------- ------------------- - --------------------- ----------------------------------------------------------------------------------------------------------------- -----•-------------------------------- ----------- ---- ------------------ -- ------------------------ ------------------------- ---------- --------- ------ -Z -- --- --------------------------------------------- - - --------------------------------- FINAL INSPECTION -------------- Date--------------/_-- - -- - SAN JOAQ I LOC AL`HEALTH`DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California ({/ Tracy, California Es---9-2M 145446 ATWOOO 12.54 /