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APPLICATION FOR SANITATION PERMIT Permit No. .. I ._ . (Complete in Duplicate) (� Date Issued Applicai-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. j This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND CATION------ ___ S Owner's Name---------- ---%-----2/1-- Phone__2?6 3- SS f Address �'� --. .y_ �. . -- — -: - ---- ----------------------:..-..---•-•--.....----...---------------------•--- ��--�------- ------ • t Contractor's Name----- - - -('--- -••------------------------------------------ -------------------------- -------------------------------- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercials❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units; __ - ber of bedrooms _1�-_ Number of baths 11�-__ Lot size - Water Supply: Public system Community system`❑ PrN6+e'❑!' Depth too Water Table 4� t- + Character of soil to a depth of 3 feet: S;%ew Gravel [:] Sandy L�am [:jClay Loam E] Clay ❑ Adobe ardpan C]Previous Application Made: Yes!❑ No Construction: Yes; E, No ❑R TYPE OF INSTALLATION AND SPECIFICATIONS: r k (No septic tank or cesspool permitted if public sewer is available within 200 feet.) FpTank: Distance from nearest well--- Distance from foundafior�-------------- Material______._____._..___________________.____.______- a f y z . � No. of compartments, -------- ----------Size----------------- - -�-------Liquid{depth-------------�-1-------._Capacity----------------------• y p ^-' Distance from nearest welf_-__---------_...'Distance from�fcundatio ___.__,_________.`distance to nearest lot line_________________ is �F ,Number bf lines; _i-:------------I------------Length of each line-----------------(-------------Width of trench--------------------- ---:-------- C Type of filter, material____'___________________Depth of filters m tenal_ ------ ____________Totalength--------:_____.______________ ------------- 1 E _Distance from fo ndatio t k � Seepag {t: Distance to nearest well ___ ___________ ___-- �.___.___.Drstan�a to nearest lot 'fe_______,.________ Number of p-ts-----/` -----Lining material------------------�;..Siz�DiameteI------ -9_- ........De Depth_ ' p ' ` f �- Cesspool: Distance from neares wellw-__ `__---_-Distance from foundation______ _____________Lining material-------------------------------------- Size: ______..___________.__ _______- eCapacity �] Size: Diameter--------- --�----------------------- -t�===�==---------- ---------------Liquid ---------------------------- - t Privy: Distance from nearest well_________________________ ________..Distance from nearest building__________.__._______.________.__________- ❑ 4 . o - Distance to nearest lot,line -- ----------------- -------- ---- - ------------------------•-------------------.. Remodeling and/or repairing (describe):---- ---------------------- ---------------------------.._........_. -------•-•---------------------------------=---•------------------------- ------•---------------j------- ---------......-------------------- ----- f --- -._ ." I �. � � ( _ ---------------- -------------------------------------------- ------------ = ---------- : ! hereby certify that I have prepared this application and that the�Work will be{'done'.in accordance with San Joaquin County ordinances, Sate laws, a ules:and:regulations oflthe San Joaquin Local Health District. _ __ /D (Signed)--------- ----------------------------- Owner and/or Contractor) Sy:-_----------------------- ..t.. a.._ ./LL [Title _ y � (Plot plan, showing size of lot, location of system in relation N'pfells, buildings, etc., can be placed on reverse side). t _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- -- - -- ---------------------------------------------------------------- DATE------- - ----------- ------ - REVIEWEDBY--------------------------------------------- - ------------------------------- ------- ---------•--- DATE-------------- -----•--- PERMITISSUED--------------------- --------• -------------------------------------------- DATE..-----------------•-------- Alterationsand/or recommendationst------------• -------------- ------------- =------------•---•-•-----•-----------------------•-•-----------------------------------• •---------•--- --------------------------------------------------------------------------------------------------•- -------------------------------------___--------------------------------------------------------------------------- --------------------------------------------------------------------- FINAL INSPECTION BY:---------=`-=------------ --- ----------------------•-• Date------------------------ - ----------- _17Y s ( SAN JOAQUIN LOCAL HEALTH DISTRICT y 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100 _ —