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APPLICATION FOR SANITATION PERMIT Permit No. ....... (Complete in Duplicate) bate issued .-----1--�- ----••--- I" Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and ins-tali the work herein described. This application-is made in compliance ,with County Ordinance No. 549. JOB ADDRESS AND LOCATION-------- ----------- -------------- ----- - ------- --- ----- -------- ----- S ` ---' f ----------• - Phone----------- -- �- --------------- ------ - ---------------- Owner's Name------ - ra ------------------------------------[---�---:-�------- � Address------ ____A. ------ ---------- -- -601) --- -- Phone-,,-,- me __. -Contractor's Na Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _1____ Num -_ber of bedrooms . Number of baths .1__.: Lot size ._,� , _________._--_.. Water Supply: "Public Fsystem X 'Community system ElPrivate ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand [IGravel ❑ Sandy Loam E] Clay Loam ElClay ❑ AdobeA, Hardpan ❑ f Previous Application Made: Yes F] No New Construction: Yes No E] TYPE OF INSTALLATION AND.S_PECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200 fee+.)IF { Septic Tank: Distance from nearest well_ :.4�✓ _Distance from foundation----/C�___._:'_A_.MatenaL�.r______.__--:" ----- - _ _Capacity....fQ -Q----- �No�. of compartment- f�.... --Liquid depth--------.�--t'.------- _ �1�1-.Distance from foundation_____-1d Distance to nearest lot line ___..."" Disposal Field: Distance from nearest well.I _. - s,_. Number of iines___--=---r_-_."�--,{----------Length of each line---------3 -- -. ��_. Width of trench-----R_V------� ".Type of filter meterialj.___".S- fDepth of filter material._____`_Total length______�� " Distance nearest lot line____e_J.__..___._ o Seepage Pit: Distance to nearest well --Distance from foundation_______ __________. � f .plumber-of pits------L_-- :--:--Lining.material_&'__e_6171Zaize: Diameter------ --------Depth---- '<-------------- W Cesspool: Distance from .nearest well------------------ from foundation__._ - "-----_..Lining material------------------------------------- Size: Diameter--------- y- -----'Depth- --•-----------•----------------- ----------------Liquid Capacity----------------------------gals. ❑I „ i _--_Distance from nearest building --- .rte a Privy:' Distance rom nearest well-----------------.------------------------- 9 -------------------- V ❑ ....:..a:i a i -� ----- --------- --------------------------------------- t. Distdnce to'nearest#!ofi lone___.'-__.______..__---_ ------- L ----- 0 t Remodeling and/or repairing (describe):-:----------------------- - E' -----------=-----------------------•-------------- --•------"-----•---__....----•----------•-------- ------------------------ ---- _ - I�hereby certify Aha+ l have prepared this application and-that the work will be done in accordance with San Joaquin:Counfy ordinances, Stat a sand rules and regulations of the San Joaquin Local Health District. , �� (Signed) t-- ----------- and/or Contractor) a $ .? -t�= ----------------------------------•(Title) ... 4 ----------- (Plot plan, s owing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). f FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY�---------=---------------------- ---------------------------= --L------------------- ---- DATE_ REVIEWEDBY--------•--------------- -- --------------------------------- `------------------------- DATE --------- "-----------------.------------------ BUILDING PERMIT-ISSUED.---------� --------- ------------------------------------------------------- - DATE.:_ - Alterations and/or.recommendations------------------------------------------------------------------------- -_-------... ----- - /{ q -•� " •a�., !` a° *°`__ ' 'ice �- ".� { - € z -- S-- e-/r/fJ------------------:--------- -------- ----._ --------."---- - -----------------------•-- -------------------------------- - - ------------------------- ---;---- ------ --- µ Y , �. ' P�_�tk �� ._ -..------ FINAL INSPECTION BY------- -- ------ . Date__ 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 ; Revised W-2100 _