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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued ------- - ---------------- A This is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. is application is mad i e in compliance with CountyOr inance No. 549. JOB ADDRESS AND LOCATION- 2. .... ..... .... . ... ----------------------------------------------------•---------•------------•--------- .Owner's Name----------- Phone_X77?v:?_.e -------- ---------- ---------------------- --------------------------------- ---------- Address------------ 67' ... ......... - Contractor's Name"-""_ --- -'`/"""-"' - -------- ----------- ---------------------------------------------------*--------------------------------- 7 ----- ------ -- -- ----- -------- Phone-------""----- ---------------------_----------------------------------- r-e----------- - M serve: Residence 2" Apartment House E] Commercial 0 Trailer Court E] Motel L] Other L] Installation will Number of living units; _44- umber of bedrooms __cL Number of baths --- Lot size e j ter,Supply.- Public system Community system E] Private El Depth to Water Table _EOff. --------------------- Character of soil to a depth of 3 feet: Sand [] Gravel Ej Sandy Loam E] Clay Loam E] Clay E] Adobe�rdpan E] Previous Application Made: Yes El No �New Construction: Yes 0 No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fank'ar cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weq-----------------Distance from foundation---------- -------- Material---------- --------Capacity--------------------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth---------------- -----------------------• ------------------ Disposal Field: Disposal Field: Distance from nearest well-----------------Distance from foundation-----------------_-Distance---------Distance to nearest lot line.---.-----_______? Number of lines . ------- t -------------------------------Length of each line------------------------- --:.Width of trench----------1` Type of filter material-------------------------Depth of filter material__".-__".""-__"_ ------ g : well___ I-_."._Total length--------------------%_ ------------------- Seepa Pit to nearest :7-777�___1lDisfanca frombLoun -----4-C D'st gee to nearest lot line U-Mber of p;fs 01 -1 ly-------..-.Dep ----------- Lining material_a� Size: Diamefe "T fh-----441 ---------- �ation Cesspool- Distance from nearest well-----------------Distance from foundation*--------------------Lining material___.-_----------------------------- r_1 Size: Diameter-------- --- --- --- --------Depth----------------------------- ----------------------Liquid Capacity Privy: Distance from nearest well-._________________----------L---------------.__ -Distance from nearest building------- El Distance to nearest lot line________..-___ --------------------- ---------------------------------------- Remodeling and/or repairing (describe):____-_-________________ ---- I------------------ ------------------I------------------------------------- --------------I------------------------I--------------------------------------------------- r---------------------------------------------------------------------------------------------------- ------------------------------------------------------------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;Ad rules and regulations of the San Joaquin Local Health District. (Signed)--------------- --- ---------------------------------*--------------------------------- ------------ r Contractor) By--------------------- _e__R�_ ------ ------ -----------------------------------I-----------------------------------(Title)-- - ------- (Plot --- plan, showing size'of lot, location of system in relation to I wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION. ACCEPTED BY"" ---- --------------------:-------------------------- ---------------------------------------- DATE REVIEWED BY ------- ----------------------------------------- -- ---- -------- -------------------------------------------------------------------------------- DATE."--&- V BUILDINGPERMIT ISSUED------- ---------------------------------------------------------------------------- --------------- DATE---- AI+erafions and/or recommendations:_"__-__"_________________ ------------------------------------------------------------------------------ ---------- ---------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- ----------------------- -------- ---------------------- ----------------- ----------------------------------------------------------*----------------------------------------------------------------- I------ ----------------------- -----------------------------------------------------*--------------- -------------- 9 FINAL INSPECTION - -------------- - �7 Date... SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Souf6 American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Led;, California Manteca, California Tracy,California. E5-9-2M Revised W-2100