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APPLICATION FOR SANITATION PERMIT Permit No. (ice (Complete in Duplicate Date Issued ___ r ya I�_ _45 - 1 Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install th ork herein describe . This application is made in compliance with County Ordinance No. 549 JOB ADDRESS AND LOC ON-.-_ = 1__ .� - r�POwner's Name - -h' one ---- --- Address------- --- ----- - --- - -l�--- Contractor's Name- - -- - -------------- - ------------------ •--------------------------- Phon 2--= Installation will serve: Residen nt House ommercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___ __ Number of bedrooms__ Number of baths __,f___ Lot size y �' ;� .��------------------------ Water Supply: Public system ❑ Community system ❑ Privateg Depth to Water Table,�ft. Character of soil to a depth of 3 feetc i Sand E] Gravel E] Sandy Loam E] .Clay Loam Clay ❑ Adobe❑ Hardpan E]Previous Application Made: Yes E] Previous ?FICATIONS:New Construction: Ye� No E]TYPE OF INSTALLATION AND SPEC r (No septic tank or cesspool permitted if public sewer is available within 200 feet.) t ptic Tank: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------._________--- I o. of compartments--------------------------Size--------------------------------Liquid depth----------------- --------Capacity--------------------- y isposal i Id: Distance from nearest well------------------Distance from foundation-------------------.Distance to nearest lot line_______________._ Number of lines-----------------------------------Length of each line------------------------------Width of trench------------------.----•_---------- Type of filter material______r,A Depth of filter material----------------------- length______________.___._____________________,- S . , x Seepa a Pit: Distance to nearest '- VDistance f m�fou anon... Q Dista`�e to nearest lot line---.15- Number of pits--- material-�___--_'� Size: Diameter__- .________.Depth____ ' Cesspool: Distance from nearest well_________________Distance from foundation------------------- Lining material------------------------------------- ❑ F Size: Diameter-------------------------------- ---Dep -------th------------------=-- --------------------- Li Liquid Capacity F _-�9 CYT �-��:-fi Privy: d Distance frorn_nearest%yell-._.-. ___________________f7r7n."13iftanc�e�from neo si building ______________________.___._____-- istan �s . _ . ❑ " Dce to nearest lot line.- == - - = -------------------------- -------------------- Remodeling an ,/.or repair ng {describe}:--- = - I - ��1 n � - -�fir''—�1�'-------•-- ----------------- - `-1---------------- ----- - --------------------------------- ---------------------------------------- - ---------------- ¢ .� . .,c = --- ------- WIZ --------------------- ----------------------------------------------------------- ------------------------------------------------- !,_114ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and r les a d regulations of the San Joaquin Local Health District. , 4 " (Signed)... = -- --- - --------------`-------------------------------------------------------------- ------ -----Owner adrContractor) t By:--------------------------- •••0•••. -- --------------------------------------------------------------•--------(Title - - - (Plot plan, showing size o ,location of system in relation to wells, buildings, etc., can be Is!_ d on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ---------------- - ------- ------------� DATES ------------------------------------------ REVIEWED BY----------- ------------- %,p '=---------` --- 1 DATE BUILDINGPERMIT ISSUED-------------------- ---------------------------------•-----------------•*y----••-------•------------ DATE------�.t------•-----.- -------•---•-------------------- dt Alterations.and/or recomme dations-------------'------•. ' . A_--------------------- l r A / -------------- ----------------------------- ------------------------------------------------- ---------- -------- ------------------ -----------------.........--•• ------------------------ ------------------------ ------------ --------------------------------------------------------------- FINAL INSPECTION ---------------------------•--•-------•-----------------------•.........-------------------------------------------------------------------------------------------------------------- - �� rw y = =--- ----K Date- -7_-------------------- ---------------- 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 _fS-9-2M ; IRevised W-2100