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APPLICATION FOR SANITATION PERMIT Permit'No. .. ........... .A (Complete in Duplicate) Date Issued 1 A tion is hereby made'to the San Joaquin Local Health District for a permit to construct and install the work herein described. I?P This application is made in compliance with County Ordinance No. 549. F r. er JOB ADDRESS AND LOCATI N-----JLC-—_f------�Z----- ---... -- - - -----------------------------------------------------q- ----------------- Owner's Name----------- -41 ------- -- •--- --- --- --------------------------------------------------- Address------------------- ----- ��_ .�-' /`"------ - ---------------•-- ----------------•-••------------- --------_------ Contractor's --------------Contractor's Name ---------j_____QL � ------- ---------------------------------------------•-------•--•---- Phone------ Q Installation will serve: Residence Cj3' Apartment House ❑ Commercial' ❑ Trailer Court ❑ Mojel ❑ Oth`r El Number of living units: _ _ Number of bedrooms _, __ Number of baths _c. Lot size ----------------------- ----- i Wafer Supply: Public sys#�m �ommunity system ❑ Private ❑ Depth to Water Table _-fdit. Character of sail to a depth of 3 fee+: Sand . Gravel El Sandy Loam E] Cl Loa E] Clay E] Adobe Er-"Hardpan [j Application Madel Yes El No' New Construction: Yes ❑ No i TYPE OF INSTALLATION.�AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) I� Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material__..._.____.______.____.._________--___________-. ❑ No. ofk`compartments_-----------------------Size- ------------------------- ---Liquid depth--------------------------Capacity----------------------- il Disposal Field: Distance from nearest well_-_.---.-__---__Distance from foundation._________________Distance to nearest lot line______`.._____._. ❑� Number oz lines--------------------- ----------------Length of each" line-----------------------------Width of trench----------------------------------- o oY filter material------:---------------- 6DtIce ate -tari --- ----f-_-Total length----------------•------:-------- Seepag Pit: Distance to nearest wl!_._____y-__.___ om oun ation___ _.. _..___.Dlstancelto nearest lot line____ __. in Size: ameter---- - ---------.Depth---t�� -- Number of pits--------- ------------Lining m -_ } Cesspool: Distance from nearest well----------------- om found -on--------------------Lining material--------.-_--.--_-_----._------_----- ❑ Size: Diameter - ----Depth-----------------------------------------------------Liquid Capacity----= ---------=--------gals. Ilk I Privy: Distance ------------------------------- from nearest building from nearest well - ------- ------- -------------- ------ 9------------- ------------------- --- -� Distance to nearest lot line--_------ ------------------------- -----------------------------------------------------•-------------- ❑ Id Remodeling and/or repairing'(describe): #----------- ------------- -----------------------------------------------------I--------------------------- ----- ---- -----_-if�------------------------------------------------------------------------ • ------------•---..-.-•---------------------•---------•--------•--------------------------•--------------- _-_--- --. ------------------ ------ -- .I� 1 I hereby certify that) have prepared this application and-that the work will be done in accordance with San Joaquin County , r ordinances. State law and rules and regulations of the San Joaquin Local Health District. J ------�"r'"`'�' ' ------------------------------------------------------- (Signed) ------_-Owner and/or Contractor) By:..... tr/�'`�- •. -- - ------------------------------------------------ --------(Title)--- -- --- ---- ------------- -- ----------:.-------- ------- y (Plot plan, showing size of�lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). I 'p1 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------------------------------------- ---- DATES BUILD E PERMIT ISSUED------------- ---- - ------------- BUILDING -- DATE �°- - --------------------------------- ---- ----- DATE------&----------------------------------------------- i Alterationsand/or recommendations-------- --------------------•--------- ----------------•------------------•-------•-----------------•-------•----------•----•--•-----.-.-.--------------------- d ------------------•----------------•---------•-------------••------------------------------------- I --------------------- ------------------------------------------ - ---------•----------------------------------••- ------------------------------•--- =---------------------•--•---- -�i-----------•----------------------- ----- M-------------- ---•------------------------------- •- -------------------------------•----------------- - ------•- --------------------------------------------- - 05 - 1�tm -------------- -= =- Date " N. _ FINAL INSPECTION BY------------------ -------_-------- �------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I� Lodi, California Manteca, California Tracy, California ES-9-2M I0-52 Revised W-2100 _ I