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APPLICATION FOR SANITATION PERMIT Permit No. ...�.......... .... (Complete in Duplicate) Date issued __________ Alicakion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance 549. 0 6 JOB ADDRE55 A LOC T ON ------- - -5555-- -- --- -- 5 555-------�._._..555. 5----�--5555-- ••- ------------------ Owner s Name - - - -- " -�- ------ - Phone--------------------- Address --- -- -- ,-�-- --•- -------- -------------------------------------------- ....-----.-.-... ---•--------------------------------- Contractor's Name-----4,f -- --------- --------•-- ----- 1'd6.---- r --------••-•---•--------------------------- Phone----------••-------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial 6_TFailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size ------7 ----x... .* _ ----5555---------5555-- Water Supply: Public system 2L-Community system ❑ Private ❑ Depth to Water Table X� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic Tan Distance from nearest well.17-4"yeaDistance from 4F10--- Materi�____._._____ o. of compartments----------2. --------Size____-_�___. 7/--U---Liquid depth.....__ _.__..___--._.Capacity.__ _ __C.- �------.-- Disposal Field: Distance from nearest well_____-�_._._Distance from foundation___-_ _P_ Distance to nearest lot line.,-------•J------ ❑ - __.5._555-5555--_Length of each line._---.---_ -- Number of lines------------- ---------------Width of trench--------�G ---=------------------ Type of filter material-_- -------------Depth of filter material----------- length-------------C----___ ------------------- Seep ge Pit: Distance to nearest well_' v4____Distance"_0r1f0___ dation----ZQ__.-_..Distance to nearest lot.line__------------- Number of pits-----I-------------Lininq material_. .Size: Diameter.-.?3............ --------- Cesspool: Distance from nearest well-----------------Distance from foundation-----.--------------Lining materialL-_-_---._._-_-_-.--._---_._-__----_. ❑ Size: Diameter--- - -----.Depth---------------------------- - ------------ --------Liquid Capacity-.--------------------------gals. 1 Privy: Distance from nearest well......................________-___--- ---------Distance from nearest building________-__--_---__--__------_.__.--r--.-. ❑ ------------------------------------------------------------_ _ .. .. Distance to nearest lot line - - - - ----------5555-•-----------------5555-- -----------------------5555-- 0, Remodelingand/or repairing (describe)----------- ---------=--------------------------------•-------------------....----------------•----••----•--------- ---•••-------- --------------- ....... ------------•-----------------------------------------------------=----------------•-----------•-----•--------------------- _.................... - ,�._._. . ----------`--------------------------------------------------------------------------------`--`---'--•----•--•------------r--------------------------------••------------------------•------••------------------------------ ---------------------------------------------- ---------------------------------- ------- --.---------------- ... - I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County , ordinances, �el , an s and r gulations of a San Joaquin Local Health District. +� ._ ner and or Contractor (Signed) `" ) �Y� Z -5555--- - -------- ---------f-------._......_-•-•---•-------------------(Title)----------------- ---------------------------------------------- (Plot plan, showing size of to"t;location of system in relation to wells, buildings, etc., can be placed on reverse side). 4 2 .-FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----. -------------------------------------- DATE--------------- - r-----= ---------- --------- REVIEWEDBY------------------------------------ --- -�-- -- ---------------------------------------------------- -----------5555-- DATE-------------- -•----------•---••----- ----5555•• ----- BUILDING PERMIT ISSi.IED---•--------------------t----------------------'=----=-'` - DATE ----------------------- Alterations and/or recommendations-.--..-.-.- - -------------------------------------•----••----------•------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------__11------------------------------------------ ---•---- ---------- ---------------------------------------�_ ----- =------------------------•------•-- --------------------------------•------------••-•--------_----•--------------.--------- --------------------------- -' - - --- -------------------------5555-- --5555----------•----------•--...._...---------------5555-- --•-- -------------------------------------------------------------------------------------------------------------- - " S;Is I FINAL INSPECTION BY:.._��C` '� --------------- --------------- Date--- --r----- .....----- .................................... 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 145446 ATW6DD 12-S4 L