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APPLICATION 'FOR SANITATION A TATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to Ae'San Joaquin Local Health District for a permit to construct and This aPPiicafioA�is made compliance with County Ordinance No. 549, n described. I install the work herein JOB ADDRESS AND LOCATION) Owner's Name ---- -- - -------- - --------- -------------------------G--------- --------12___�----- -_ - - - -_ ------ ------------------------------------------ Address------------------------------------------- - - --------- -----------I Phone -- -------------------- --- -------------------- Contractor's Name_..""-._._"." -------*--------------------------------------- ------------------ -------------- -----------_--------------------------- Phone-.-. Installation will serve: Residence E] Apartment House 0 Phone-.-.". - of living units: _17��umb Commercial El Trailer C t ❑0 Mote] Ej Other Wafer Supply: public system ��f bedrooms _-2—ITurnber of baths ----��e ----------(,, __ 2��Community system [] private E] . _15 Depth to Wat;r Table ft.. - Character of soil to a depth of 3 feet: Sand D Gravel Adobe Clay 0 Sandy Loam ❑ Clay Loam E] El 1§_Hardpan 0 TYPE OF INSTALLATIOWAND SPECIFICATIONS: :f (No septic tank or cesspool permitted if public sewer is available within n 200 feet.} Septic Tank: Distance from nearest 1well.A/0NIP - .Distant Q fro m.fouin No. of compartments----- �afion__/O A ------- "-.Material---------------Size-----�K- Liquid depth------a Disposa'l Field: Distance"from n' ---- --------- iarest weil-N041e-Distance from foundation--. Capacity Number of lines""'--_--_.""------ ----- Length of each fine"_-- - - -----/---Dislance to nearest lot line------ --------- ___ j_........ t &_11I Type of filter material Width of trench._--------_- . --------- ------------Total length------- Seepage Pit: Distance to nearest well_-----.-----_--_-----Distance from foundation____."-------------�Disfance to nearest.lot line-------- d-----------------Lining material__""-- - --------- Cesspoo): Distance from n 7 1 - -----------Size, Diameter-----------------------Depth---------------------------------- earest well--------"__------Distance fro ' ❑ m foundation. Size: Diameter------I--------------------- ----------Depth* -------------------Lining material_.._.__"-_"_"_" Distance from nea rest well------------ I------------!---------------------------------------Liquid Capacity_---_-I -------gals. El Distance to nearest lot line------------------"--"-- --_ ------------------Distance from nearest building------------------------ ------- Remodeling and/or repairing [describe):- - --------------- ---- ----------------- ------------------------------------------------------------ --------------------------------- - ------------I-----------------------------------------------------; ------------------------------------------------------11------------------------I-------------------------------:---------------- -7-------------------------------------------------------------i------------------------------------------------------------------------------------------------------------------------ ------------------------- ---------------- - ------------------------------------------------------------------------------------I------------------------------------------------------------- -- ----------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------r------------- ------ 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. and r0l 5 and regulations of the Sa Joaquin Local Health District. [Signed)-\ - y- -------------- -------- ------------------ ------------------------------------------(Owner and/or Contractor) (Plot plan, showing size of lo B ------------------ --- �h e S a 0 ---------------------------------------------- ----------------- t, locafiO"--"-f'-SY-sf-e-m--in--r,e,lafio--------------- -----------------------------------(Tite -------------- n to wells, buildings, etc.. can belplaced on reverse side). FOR DEPARTMENT APPLICATION ACCEPTED BY_--.---.._- ------------ BY------- BAlt - - --REVIEWED BY --------------------------------- DAT E - _- -------------------------- ---__UILDNG PERMIT ISSUED - ------------------ - ---- DATE--- ------ ---------- --------------5------------------------- A ------------------- ----- ------e--r-a--t--i-o--n--s--a--n--d--/---o--r--r--e--c-o---m---m---e-recommendations--------recommendations----------- ---------------------------------------- - ----------------- ---------D-----T---E------------------------------------------------------------------------- - ------------------------------------- ---- --------- ------------------------------------------------------------------------------------- -------- I-------------------I------------------------------------ . ---------------------------- -------------------------------------------------------------------------------------------------- --- ---------------------------------I-- ------------------------------------------------------------------------------r�---------------------------------------------------------------------- --------- --------------------------------------------------------------- ......------------------------------------------------------------------ ---------- ---------------------------------------- ----------------------------------------------------------------------- - . ........ o� ------------- FINAL - --------FINAL INSPECTION BY. .......... .. � -------- Date_ SAN JOAQUIN LOCAL HEALTH DISTRICT 130,South American Street 300 West Oak Street Stockton, Cal;forniaLodi, California 132 Sycamore Street 814 North "C"• Street ES-9-2M 10-52 Revised W-2100 Manteca, California Tracy, California