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APPLICATION FOR SANITATION PERMIT Permit No. 19 (Complete in Duplicate) /4Date issued V 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 Ordi ante NO. 549 JOB ADDRESS AND LOCATION_ 1002-47, f----- Owner's Name--------------------- ------------_----- ---------- ------------- - -------- Phone-i -W-d-13.2- Contractor's Name------ Address----------- ---------- -- -------- --------- /Y/�p- - ----------- ------------------------------- ----------------------- e ---------- C-9------------------ -------- Phone-{ --------12 Installation will serve: Residence qj-"'Aparfment House E] Commercial ❑ Trailer Court E] Motel Ll Other L] Number of living units: /_ Number of bedrooms I<Number of baths 4'03 Lot size ----� ----------------------------------- Water Supply: Public system eCommunity system E] Private E] Depth to Water Table 1dft Character of soil to a depth of 3 feet: Sand [] Gravel E] Sandy Loam El Clay Loam EJ Clay EJ A�io_be�a'rclpan 11 Previous Application Made: Yes [:] No �ew Construction: Yes El No P--- HA/VA: Yes E] No Ee�� TYPE OF INSTALLATION AND SPECIFICATIONS- (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) -Stic Distance from nearest well-_______________Distance from foundation--------------------Material---------------------- *t No. of compartments------ -------------------Size-----------A._.._.__.-....:.-.Liquid depth--------------------------Capacity----------------------- —1c os e Distance from nearest welh_' Distance from founclation_ ----Distance to nearest lot Number of lines-----_:----------------------------Length of each line------------------------------Width of trenc'h----------------------------------- Type of filter material_-____-_________________Depth of filter material-----------------------Total length__--_----____________________-____--__-- ` See e ength------------------------------------------ Seegae Pit: Distance to nearest weII_A0_M4'____Distance from foundation---42--------Distance to nearest lot e4l Number of pits-__.j----------------Lining maferial__i� 4A-------Size: Diameter---15-3----------Depth____Z--7__,--------------- Cesspool: Distance from nearest well-________________--Distance from foundation------------------- Lining material___-__---__---_______________________ ❑ Size: aterial------------------------------------- Size: Diameter----------------- Depth---------------------------------------------------Liquid Capacity------------------ --------- -------I- ----------- gals. `�Ik------------------ -----------------------------Distance from nearesf building________-_______________-_____.____.____._ Distance from nearest we El Distance to nearest lot Iire��------------------------------ --------------- - w ti ------------ --------------- Remodeling and/or repairing fdes cr ibe):---- /I --------------------------------------------------------------------- _T---—- ------ 'A"?- ------------------------------------------------------------------------ ------------------------ ;01-215 P- ------------------------ i---------------------------------------/-------------------------------- - --------------------- --------------------------------------------------------------------I----------------------------------------------------------------------------------------------------------------- --------------------------------------- ----------------------------------------------------------------------------------------------------------------I------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin L a] Health District. (Signed __A 49-- -- ---- --- ---- --- -----------------------jCWwvr_-m5_%WContracfor) By:_------------------------------------------------------------------------------:-------------- - ------- ---------- Me)------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to we , buildings, etc. an be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ -------------- ----------------- ---------------------------------------- DATE----------------------- ------------------------------------- REVIEWED BY - - -- - - - -- - ----- - - --- --I ------------------------------------------------------------------------------------------------------DA--T--E--------_)-----------h0- - -- - --------------------------------------- BUILDING PERMIT ISSUED-------------- ---- ----------------------------------------------. DATE- ----------------- - ------------ --- - ------ , Alterations and/or recommendations________________ -___-__--- ------------ ecommendations:-------- ---------- ------------ __tk---N --------- ------ --------------- ------- ----- --------------- -------------------------- - ---- --------------- -------- -------------------------- - --- ------------ -- ------------------------------------------------------- -- ----------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- ------------------------------------------ --------------------------------------------------------I-------------- -------------------------------- FINAL INSPECTION BY:__----- Date-----To---)_1 ------------------------------------- ------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2 M Revised 1.57 FY.CO.