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f w APPLICATION FOR SANITATION PERMIT Permit No. ---------------- (Complete __._..__/_ ..(Complete in Duplicate) '�'• • - - � _ 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 i•nade in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION._ _ --••----------------------------------------- Owner's k - - ------------------------------ ----------------=------------------- Phone .----•---------------• --- - Address------• ' ------------- --------------•----------- ----------------------------- -------- Contractor's Name ------- - ----- - ,eS - - r •-------- Phon -------- € --- — Installation will serve: Residence 11_'partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ J Number of living units: -Number of bedos 4 h,+,. . / i -4. /!s t— -_ ' Motel ❑ Other-------�--------------------------- -- -- / -•-- __Y _ __�_....,__.-,._r,,, ..._..-Zbo �a,iu '�rav�i LJ oai%i-y mfn Cj;`tlay Loam-Ej Clay 0 Adobe atclpan El Previous Application Made: Yes ❑ No 2f --New Construction: Yes ❑ No TYPE OF INSTALLATION AND. SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wel#----- ___.------ . Distance from foundation ------------ -------- Material _______________.____- No. of compartments------------ ------------ Size ---------------------------- =--- Liquid depth -------------------------- Capacity_.--------------------- isposal Field: Distance from nearest well-___.-_,__________ Distance from foundation ---------------- {o nearest lot line________ _________ ` Number of lines --------------- -- ------------------ Length of each line_- -------------- -------------- Width of trench.----------__--- ------------------- Type of fil r m --------- Depth of filter material --.__________.___-____Total length________.__.________.____.---------------- Seepage' __ /---•---r ---- Seepa�g�Pit: Distance to nearest well_ Distance from f-undation__.. •� ---- , q �t��...__.._.D�stance to nearest lot line -Z& __._ Number of joi,ts--- _______Lining material -A -----Size: Diameter:_ZC_'----..De th--___. Cesspool: Distance`fi-em,nearest well ----------------- Distance from foundation.__._ ---------------- Lining material__.____-.___________- ❑ Size: Diameter-- = Deoth i s - ----- - ----------- Liquid Capacity -------------------------- --gals. Privy: Distance from nearest well__.___.____.______ �y ---------------------- -Distance from nearest building----------------------_- = ❑ Distance to nearest lot•line:--"--::_ ----------- . , �4 _ - ----------------------=------ -------= . Remodeling and/or repairing (describe):_.__--_______________________________ ------------------------, i 1 •----------•-------------------------------•------- - •---------------------------------------- --------------------------------- `t --------- -------..- - i .. w ^-------------•--------------•--------•----------------------•-----------•-----•-•-----------`-----------------------•-------•----------------------------------- I hereby certify that I have prepared this application and'that the"work will be done in accordance with San Joaquin County .4 ordinances, State laws, and rul s and regulations of the Sari Joaquin Local Health District. Y " (Signed) Contractor) By' ---...'--tom- - ^• --- -'r - - -- It _� (Title}--��.' !M ------------------ - (Plot plan. showing size of lot, location of system in relation to wells, buildings, etc., can be -placed on reverse side). ` FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- -- DATE -� REVIEWED BY DATE ------------- --- x;-------------------------- ----------------- BUILDING PERMIT ISSUED ------•----------------••-----_---- -- -- DATE----------_--- � S Alterations and/or recommendations:--------------------------•-•----------------•------•-----=-------•-----------_-------••---• ------••------------- <'_ ------•---------- --------------------------------- I.. ---------- FINAL INSPECTION BY:-- '-• Date % %-- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES ---9-2M Revised W-2100