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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Permit No. _..':S__�`.--tu Date Issued Applicaa-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 County Ordinance No. 549 - -7 JOB ADDRESS AND LOCATION.-- D 0� 7,0 - �. _ _------- --- -------------------------------------------==---------------- Owner's Name ----------- ------- / ------------------------ Phone - Address ---------- hone-Address----------"'� 1 " • --------------------------------------- -------------------------•----------------------------------------------------•-----------=---------- Cantractor's Name f/_. _ - -,�_ -- , `- one % d biz 6 ---------------- Ph •- ----•---•• --: --------------- Installation will serve: Residence E4—'j�artment. House ❑ Cjmmercial ❑k Trailer Court i❑ Motel El Other E] t Number of living units:�t.l--___a Number!of bedrooms . _Number of baths _ Lot size r-�------- - Water Supply: Public system ElCommunity system F]Priva.te-<�Depth toiWater Table �`5__ ft. i.. Character of soil to a depth of 3 fee': Sand [] Gravel ❑ Sandy Loam .❑ Clay Loam ❑. Clay El Adobe Hardpan E]Previous Application Made: Yes ❑D---Ne,;No Qw Construction: Yes E] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available�hin 10 feet. SLS I Septic Tank: Distance from nearest well__------------- Distance from four dation_-._.__________.Material_ _-!_____-_'-_____-_.-_____.-------- ------------------------- ____ No. of compartrrents ° Size: ----X------ ---------Liquid depth------v---------=-Capacity `�'S d Disposal Field: Distance from nearest well__S �_ `._ Distance from foundation-------------------- Distance to nearest lot line --- ej �___ �f, Number of lines�_e_._____--- __-_}-------------Length of each line ------ 3_a__._____.-----I-Width of trench.--�-y_"---------------•_-- { Type of filter material---r'rCf_c�______ Depth of fil er material--/,?""* ----1-Total length� o'__________________________ Seepage Pi Distance to nea est well___'- ----------- Distance fr m foundation_____7s'_-!i_.Distance to nearest lot line__`d....... Ss a Number of pits------- --_------------- Dept h ----- ^.---•---••-----...: Cesspool: Distance from nearest well`____ 4 Distance from foundation ___ ------ _------ 1 --- Lining material ------------------------------------- Size: Diameter---___ ----- -- - _--Depth ----------=-----Liquid Capacity ---------------------------- gals. a..� ,_. Privy: Distance from nearest•well---------------------------------------------- --- Distance from nearest building_____________________ ❑ Distance to nearest lot line------ -----------------------------------------•------------ Remodeling and/or repairing {describej:----------------------------------------------•---------------------------•-•-------•-------------------------- . 1 . -------------- ---•-----------------•--------------------------------•------------------------------------•----------------------------------------------------- ---------------------------------- ------------------------ ------------------------------------=--------------------------------------------------------•------------------•-----------•---------•---------------- ----------------- ... ------------------- -------------------------------------------------------------------------- •--------------------------------•-----------------------------------------------------------•--• ------------•-•--------------------------------- 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 rules and regulations of the San Joaquin Local Health District. r (Signe�)-----------------------------------'-'----------------------------------------------------------------------------------------------•------------- (Owner and/or Contractor) , By_______________________________________________________._______-___________.____----_________...___•___________.-_____________-._.__(Title}_-.-__..________..-__-.____-___________.________.__--- ..___---- (Plot plan, showing size.of lot, location of system in relation to wells, buildings, etc., can.be placed on reverse side). # y FOR DEPARTMENT USE ONLY APPLIICATION ACCEPTED BY---- ----i---------------------------------------------------------------- DATE--------------c� i REVIE WED BY -------------------------------- - ------------------------------------------- DATE------- f r `�� -------------------- ---------- BUILDINGPERMIT ISSUED ------------------------------------------------------------------------------------------------------ DATE------------ Alterations and/or-recommendations:;---------------------------------------------- -- ----------------------------------- . ---------- -----------------------------------------------------------------------------------------------------------------------------------------------•----------------------- ------------------------------- ----------- I ----------------------------- -------------------------------- -- -------------------------------- ----------------------------------- ------------------------------------------------- ------ _-___..__- 4 __---------------------- .--------------------- ------- .-------------- ---------------------------------------------------------------- ------------------------ .__.----------------- ._-_________.___.___- FINAL INSPECTION BY------- ------ ------------------ Date---------- -,5 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" S+reo+ Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised W-2100 r C* rf