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�To L 1) APPLICATION FOR SANITATION PERMIT Permit No. ---- -- ` O (Complete in Duplicate) Date Issued ---- Application is hereby made 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. JOB ADDRESS AND LOCATION . --------------A�k4 •-'Coe_/--------------------------------------------------- ---2 ------- ------------- ------------- Owner's Name-------•---•- ---------- Phone-------------- --------------------- ------------------------------------------------------ ------ ---- I Address-------------- ------------ ------------- Phone--- a__V - -- --- - - - -------- ---------- ---- -- - - --------- Contractor's Name--- Installation will serve:j Residence iApartment Hops! rl Commercial F] Trailer C)urf 0 Motel 6d-X-Q Other [3 _4�- � - -- -1----7,51------------------ Number of living unifs:'2- N 6'r.of=bedrooms -- -----Number of baths -- Lo size ---- ckn`117�6 y system e F0ate E] Depth to Water,Tab "---ft. Wafer Supply: Public ..-M C 1 r-if m le Character of soil to depth of 3 feet:j 'Sand E] Gravel L] S6n,dy Loam [;,,Oay Loaln El Clay E] Adobe A—<ardpan Previous Application Made: Yes El No E] ew Construttian.Yes TYPE OF INSTALLATION�ANCi-SPECIFICATION,5:� A (No septic tank or cesspool permitted if 4 ublic sewer is available within 200 feet.) Septic T Distance from nearest well"ril---------Distance from foundation___________-i------Material------------------------------------------------- - I ._.; , - A � I-------- _7 ------------t----------Liquid depth--------------------------Capacity----------------------- EIA No. of comparf Size.,.. Tank:` Distance fr(;m.-nearest we"I I --------`DistancMom f(oundafiori------------I-------Distance to nearest lot line_______________ Disposal I d Dis 1 from ._nearest Numbertoi", lines-------------------------I Length `of each 1,1;ne------------------------------ Width of french -- Type of filter materi y al__-_____.-- __}___._ Depth-of,filter material---------------I_ _____Total length_________- --- --------------------------- --- Seepage Pit: Distance frym if o4n d a ti o n /Z-dr --__._.Dist ance to nearest lot line__._ ----------- Number of Pits__Z04___ Lining material-,45U.*�6....Size: Diarnef r----- --------Depth-----?--5------------------ we -------D odri�afion---- ---,-,-.Lining material---------- Ce-s-spook, Distance from nearest well_______ _______ isfancel from f --------------------------- I I i F-1 Size: Piam -A Depth ----------- --------.......... ------Liquid Capacity-- ----------------- -------gals. jefer-, ---------- --------De ---- - -- Privy: Distance from nearest ------ ----------Distance from nearest building----------------------.---- ----------- lot line------- El Distance to nearest ---------------- ----------- --------- ------------------------------------------- ------------ Remodeling and/or repairing epairing [describe):-------------- ------ ------ ----------------------------------------I---------- ----------- ----------- --- ---------------- ------------- -------------------------------------------------�:_�------ - ------- --- ----------------------------------- -------------- -------- ------- -- ------------------------------------------------------- -- ----------- ----------------I_--------------It------------- -----------i--------------- -------------- --------------------------------------------------------------------- and that f in accordance with San ----- ----- I hereby a aye prepared this application' �e work ill be done Joaquin County ordinances, State laws, and r?ules regulations of ffie San ��Jl oaquin Local Health Disfric?t.�? --------------.(Owner and/ Contactor) -- ----- -- -- ---- ------- - -- -------------- (Signed)----- ---------------- L--------------------- ------------------------1-----------------------------(Title)- )Vf - -------------------- I ic�.-_�!n be placed on reverse side). (Plot plan. showing size.e of lot, location of system in:relation to wells,ibuildings, e FOR DEPARTMENY- USE ONLY t - APPLICATION ACCEPTED BY ----- ----------------------------------IDATE------ ------I --------- T2 - ----- -------- - - ----- ----------------------------- ------- REVIEWED BY---------------------------------------------------------------U------------- -------- -------------------- ------------------�:------------IDATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------- - --------- -------------------------------------------- DATE--------- ------------------------------------------------- Alte ti rnendations: ra -- ------ .dfi ns and/or recorn ---- --- ----- ------------------------------------------ A-------------------------------- ------------------------ __----------- ------------ --------- ......... .. I ------- ------------------ ----------- ------------------------------------------------------ ------- --------------------------------------------------------------------------------------------------------------------- ------------------------------- -------------------------------------- --------------------------------------------------------------------------------------------- ----------------------------------------------------- ---------------------------------- ----------------------------------------- ---- ---------------------------------------- ----------------------------------------- FINAL INSPECTION BY: ------------------------------------------------------- Date----- ........ -------------------------------------- ---- ------------- ------- SAN JOAQUIN LOCAL HEALTH DISTRICT 4 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California CS-9-2M 10-52 Revised W-2100