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APPLICATION FOR SANITATION PERMIT Permit No. ........................ (Complete in Duplicate) Date Issued _5P �3 -4 3 -------------------- A y made Application is hereby to the San Joaquin Local Health District for a.permit to construct and install the work herein described. application is made in compliance with County Ordinance No. 549./ - 11 JOB ADDRESS AND OCATION------- – - ------------------- ------ ---- ------ ----------/1 Owner's Name-------- - ------------- ------I- - ---------------- -- -- ---- -- ----------- Phone-- Address............. Z ---- ----------- ------ -------------------------------------------- ------------------- /10 V Contractor's Name'to`� --------- _^----- - --- ----- ------ -----------R---------------------- I Installation will serve: - Residence11 �_� Anp rtment ouse ❑ Commercial ❑ Trailer Court ❑ Motel E] Other 0 Number of'11ving units; 1----- Number of Mr-o"o Number of baths J_ Lot size --- -------------- V ------------ Water Supply. Public SyStE M Community.7ystemEl Private Depth to Water Table Character of soil fo,-a depth of 3 feet: Sand Gravel E] Sandy Loam ❑ Clay Loam E] Clay ❑ Adab Hardpan E] No New Construction: Y No E] -previous Application Made., Yes E] V-) TYPE OF INSTALLATION 'AI ND SPECIFICATIONS: (No septic tank_Qr,ce'sspool permitted if}public sewer is available within 200 feet.) Z........Materia) Septic Tank: Distance from nearest w - /"/` ----- __ -------------- �e well __ -_Distance from foundation ----- -_-.--__Materia Capacity...- _e ----Liquid dep�h. No.:of compartments------- Size ---.Distance from foundation---- -------.Distance to nearest lot lire---- ---------- Nurfibe Nurnberg of lines---------- - -----------Length of each line----C-:7f 5r .Width of trench------4------------------------ DiAspos I Field Dis"faric from nearest we€i xla\� Type of filter material -----Depth of filter mafc -----Total length------ --------------- Seepage Pit: Distance to nearest well- ------- ----- ---D stance fr. M fo ciation------S7----------Distance to nearest lot line---- --.Size: 1 / 11 ----------- -------- Number of pits--------- ----------/Lining maferi 11 Size: Diameter-_-`?_ Depth.... 1A C-11 Cesspool: DistanAe from nearest well-----------------Distance from foundation--------------------Lining material------------------------------------- El Size: Diameter---------------------- --------------Depth---------------------------------------------- -----Liquid Capacity-.--------------------------gals. Privy-. Distance from nearest well-------------------------------------------------Distance from nearest building------.---------------------------------. Distancerto uilding---------- ------------------------------DisfancLto nearest lot line--------------------------• ----------------------------------------------------------------------------------------------r--------------- Remodeling and/or repairing (describe):--------->ix --------r--------------------------------------------%----------------------------------------- -------------- ---------- ----------------------------I-------------------:--------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------I--------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------•---•---...- ------------------------------------- -------------I----------------------------------------- certify -------------------------------------------- ---------------------------------------------------------------------------- '�I hereby that Ihave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and requalationsoff the San J;oaoin Local Health - ------ Healh---D---is--t-rict. (Signed)_--D- _n -- - (Owner ndlo. Contractor) " / W, {Title) ---' By:.......... .r - ----- ------- - --- ------------------------------------ --------- 17 (Plot plan, showing size of lot, location of system' in relation to wells, buildings, efc., can be laced on reverse rsi e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_- ------------------------------ ---------------------------------------'-_=DATE__;:.e------ ---------------------------------------------- ------------ --------------- DATE-----1��w----------- ------------------------------------ REVIEWED By---------------------------- ---- --- --- BUILDINGPERMIT-'ISS.UED_/--------------------------------------------------------------------------------------------------- DATE--- ------- -------------------------------------------- Alterationsand/or recommendations:---------------------------------- ----------- ----------------•----------------------------------------------------------------------------------------------- -- - ---------- ------ ------------------------------------------ i. ------------- ------ ---------------------- ----------------- _4 ------Z------�40 ----------- -------------------------------- -------------------------------------- --------------------------------------------------------------T--------- --------------------- -------------------------- ------ ------------- ------------------------------- -------------- --- --------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION ---------------------- ------------- Date--- ------- ------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American St] 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M i0-52 Revised W-2100 1I