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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) �A /-� Date Issued .._._____.�_________ Applica}ion 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 Count Ordinance No. 549. c JOB ADDRESS AND LOCATION...---- --- -SSC' /�1_`�,e ----..'-----------�ee��x..c�---------- ----- ----------- --- 9. Owner's Name = dS,. Phone - �Q.----•---•---- Address-----------------------------------1 ------------------------ Contractor's Name-------------------------------------- f 'sJF _ s ------ Phone-A_!(,f4k Installation will serve: Residence []Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I___ Number of bedrooms -`Y Number of baths J------ Lot size -- .. --—-`______________ Water Supply: 'Public system ❑ Community system ❑ Private Ee-tepth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2--'Hardpan ❑ Previous Application Made: Yes ❑ No �ew Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool pe`rmifted-if public sewer-is-available-within-200-feet:) � � •-- tic T Distance from nearest well_________________Distan a from foundation-__________--.__.Material-------------------- --------------------------- Na. of compartments--------------- Si�e -----------------------Liquid depth-------------------------- ----------------------- lCapao fy---------------------- D• po al�tdtd: V Distance from nearest well.._. __ .rDlls an e.from foundation __.__.Distance to nearest line._1i!0_ Number of lines____ ______________________7'Len fh of each7ine__ _ __ , Width of trench____'_ I-��_.____________-- g ----- y y �c .� Ty e of filter material__ _. _. __Depth of filter mater�al____.��__._______-Total length__'-__�Q____--------_____________ Seepage Pit: Distance to nearest-well----------------------Distance from foundet'ion___=____j_.-_.Distance to nearest lot line----------------- umber of its-------------------- ' ❑ NP --Lining material----------- -- -- Size: Diameter------------------------Depth��..-------------------- _--- Cesspool: Di stance from nearest well_________________Dista s e from fopundation`s'-_.._._...__I__..Lining material__ _�-__-_______.____________-_._. Size: Diameter:---------------� be fli,._- -______-___I--------•---- ----------- ----Li uid Capacity I gals. �� Distance from Barest building ii ! Priv Distance rom"near"est well-__.--_-_. { f )------------- ❑ •' Distance to�ea,restflot line--Z ''1r------ ----_. ---- ------------------------- c Remodeling and/or repairing Jdescribe):__._,_.. _ '" .��'c�."'_-""'"-__"='___�'- ? -- -- = -------------------------------------- -•--_----•-- i i t- -� _ ] ------------ -------------------------------------------------------------------------------------------------------------------- -7o -•---------------------- 1 ------------- ;; --- ---------------------------••------------------------ I hereby certi hat ]-have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aw , and r es an I regulations of the San Joaquin Local Health District. (Signed) ��lhc� ----- ------------------------------------------ - -------------------------Fced Contractor) F $Y;..................................................F-----•------•-------•---------- - -----Z- ---------- -- - (Title)- -�=� - ---- --------------------- (Plot plan, showing size of lot, location of system in relaf' to wells, buildi s, etc., can be- plon reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- - ------------------------ -------------------------------------=-- DATE--.Z--------------------------------------------------- - "REVIEWED BY-------- ---------------------------------------------------------------- DATE__. ._^_' ----------------------------------------- -7 PERMIT ISSUED DATE-- ------------ ---- -"', 59, e- • ---------- ---------•-------------------------------------- Alterations and/or recommendations-----------------�---------------------------------------------------------•-•----.....----•-••----•-------•--•---------...--....(�`--- --------- --•-----•--------------------------------- --------------------------- ---------------------•----------------------------------------------------------------------•-----•----------------•------•---------------- i__L'^ ..........� ----------------------- �_--____ _ ------ ----- ------------- ________ __ __________ _ ____________ _ _......_-_.._____-___.__.____________--.-___-____________-.._ _-____-_._-_-___..._________._.________..____--_________._.___-__......___________-_-- 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