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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) J'y -Date Issued Application is hereby made to the San Joaquin Local Health Districf for a permit to consfrrf and install the work herein described. This application' is made in compliance with unfy Ordinance No. 549. j? -wr JOB ADDRESS AND OCATION------- ----- ---- -------- XL . ........... Owner's Name---- ------r------ --------- --------------- �C -one------------------------------------ Address--------------------------------- --- - ---------- Contractor's Name_________ --- - ------ - -- - - - - --- ---- ------------------------ Phone Installation will serve: Residence Aparfmenf House E] Commercial 0 Trailer Court E] Motel E] Other ❑ Number of living units: Number of bedrooms j--- Numb I Number of' ----- Lot size ------ Water Supply: Public system ❑Ej Communify system -E] Private k-15'epth to Water Table dft. Character of soil to a depth of 3 feet: Sand El ardpan ❑ ,olb-ravel E] Sandy L Loam E] Clay E] Adobe Previous Application Made: Yes E] No *00New Construction: Yes o�r No 01ay TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) f d I- Septic T Distance from nearest wel('f- Distance fro M r, L- ------ m cyn a ion-------------------I --- ----- -- - ------ ❑ No. of compartments------- -------_ Size_ 4_r -----Liquid depth 4 Capacity--- -------- Disposal Fie Distance from nearelif wellSid--------Distance from founclation__J_�'._ - Distance to nearest lo ane-, of each line----- of trench_---- - ------- E] Number of lines_______/______ �O Type of filter maferia1_K_xUk____Depfh of filter material---- -------Total length---------Fla- ------------- ------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line___------------I 0 Number of pits----------------------Lining material-----------------------Size: Diameter-----_-----_-----------Depth---_-----------------------_---_! Cesspool: epth--------------------------------- Cesspool: Distance from nearest well---------- ------Distance-from foundation----------------------Lining material_________-______-------__________-___. ❑ aterial-------------------------------------- El Size. Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest wefl-------------------------------------------------Distance from nearest building---_-________________________ ---------- El. Distance to nearest lot line------ ----------------- 1�----------- ---- ---------------------- --- -- ----- -------------------- ------------- Remodeling and/or re airing (descr*ibe):--------------- ------- --------- ---- -------- ---- -- -- ------------------------------I------------- ------------------------------------------------------------------------------------ -- ------ -------------------A---------------------------------------------------------------------------------------- ---- Z ------------------------:-------------------------------------------------------;�--------------------------------------------------------------------------------I-------------------------------- ------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ✓ ordin'iinces, Stafe la Xtd rules and regulafiops. of the SapJoaquin Local,H!a#h District. I (Signed).. ;(Own and/or Zontracfor) 011* ----- -------- 1,47 of --- By: 1-------- - ---------- ------------- - ------ - ---------------------------------------------------------------(Title (Plot plan, showing size of 10f, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_S_--------------------------------------------------- ---------------------------------------- DATE- REVIEWED BY_. A" ------------ DATE_- # BUILDING ATE----- BUILDING PERMIT ISSUED-------- -------------------------------------------------------------------------------------------- DATE------- __!V� Alterations and/or recommendations-------------------------------------- -- -------------------------------------------------------------------11c, ----------------------------------11-----------------------------------------------------------------------------------------------------------------I----------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------I-------------------------------------------- ----------- --------------------------------- --------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------- ----------------------------------- V Date--------- B' ------------ --------------------------------I-- --------------------- ------------------------------- ----------------- FINAL INSPECTION Y:------------ 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 ES-9-2M 8-51 Revised W-2100