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r(X APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) c� Data Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and i't�l# he QRrh reniescribed. This application is made in compliance with County Ordinance No. 549. ` JOB ADDRESS AND- A---IQ'N"-------�- --i-�1,----- _-�: ------------ _.. - =- _ ` -r -,_"tea ., •-- � v. . - ------• - Owner's Name---------- --- �- -- Phone----• ---•---------Address---_"---- - ---------------------- = ------------------------=--- Contractor's Name-,... -----•=------------------- Phoney (� Installation will serve: ,Residence Apartment House ❑ Commercial ❑ , Trailer. Court ❑ Motel ❑ Other �] r Number of living units: _-- _-- Number of bedrooms _0--Number of 'baths --- --- Lot size """_--"_, Water Supply: Public system 9- Community system ❑ Private p Depth to Water Table------- Wafer Character of soil to a depth of 3 feet: 1 Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam E] Clay El , ,AdobeHardpan E]Previous Application Made: Yes ❑ No � New Construction: Yes � No El TYPE OF INSTALLATION AND SPECIFICATIONS: l (No septic fank;or cesspool permitted if public sewer is available within 200 feet.) ''II ,rte Septic Tank: W - -'Distance from-neares+ well-_AY ,-Distance from foundation_.1l�:�_:-•--"'Materjl__: ------------------ -- -- ------- /f No. of compartments-------- ------:-----Size----s " JY_, jc_ O EK --------------Liquid depth------��' ---------------Capacif) " Disposal Field; i - Distance from nearest well__yV stance from fouricla+ion-_ � 'f - Distance to nearest lot lin Number of lines---------- x - .� J © gr �-------•-- ? p' l� "f-_rl"_""" ;Length of each line="--.----". ---_-_" Width of trench.- .jSl ' -- ------ Type or filter material ," rDepth of filter material".--" -- ..-"Total length_-"--- `G^ 4 F �. eepage Pit: Distance to nearest well_-"""_ �?'t- Distance from our�d�tion----G--•• Distanee�fio nearest lot line .r - - ' m Number of pits------- Linin material '. e:{Diameter-__ ` d � 9 � --`---- -� ------- Depth- ---�. j -- Cesspool: Distance from nearest well_"----':"""-_-"-Distance from foundation-.''' [ �_:_ p ,. E r -.Lining material--------------------------- ❑ Size:"Diameter --- ---- - --De th------------------- - ---:" v .p . - : Liquid Capacity -- --------•--------- gals. Privy Distance from nearest well_:=""_-__-" T.h �` 7� y _-, .Distance from nearest building 5 ---------•-- El Distance'to nearest lot line-"----�'�_'�_'�°-_-----------------1, t•.€-T,�..R.� ,,#�°�„� - ---------- _ -- j ---�• r Remodeling and/or repairing (describe)----------------- .f i? . 4 � I f € - ------- ------•------.•----- ,. .. ; t --------- --------`-------••---------------------- .�. .�..t ------------------------ -------•------------------------------------ ----------------------------------- ""- -------------------------------------------- --------------------------------------------..----------------------------------------------------------------- I hereby, certif hat I have prepared this application and that the work will•be done in accordance with San Joaquin County ordinances, State aws and rules and regulations of the San Joaquin'LocaE'Healfh District., E r ...:: (Signed)-------- --- '------ -- �: 1 k � -------------------------------------------------- "------------------(OW or and/or Contractor) r� ..�,,,{ � .... . BY- _ ..-'- . "- (rifle)-------- (Plot plan, owing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY , APPLICATION ACCEPTED BY----- ----------r---."" DATE REVIEWED BY �--- ---?----------------------------- -----. DATE--- '# BUILDING PERMIT ISSUED-"""__..-""""-"""._ - = ------ DATE---------- 5) Alterations and/or recommendations:- ------------ ------------•--------------------------.------ - --------•-- --- ,�------------------------------- ------------------------ ---- -- - ------- __14--------- ---------- ----- -•- 1G� rG�°_. H ------•-- ------------- ---------• ------ f ------------------- FINAL INSPECTION BY:. --- --_------------------ --------------- Date--../ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Strest 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100