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APPLICATION FOR SANITATION PERMIT Permit No. ........t S_7 (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 made in compliance with County Ordinance No. 549. � L 2-1 JOB ADDRESS AND LOCATION..------- I -__Nl?--94(111.1j1a17--- n-----------C3?7�!-P�j-----------------------------•-.•---- Owner's Name-------------------------------------------tqR..---Tess-e------�c-elIVAL'-8y------------------------------- Phone- Address-------------------------------------------------------S--dt-77-49 hone Address-----------------------------------------••------------S--dt-71_-49 ------------------------------------------------------...-----------------------------------------------•--`-------------•--- Contractor's Name-------------------------------•--- ---------4-/7 G '------------------------------------•--------------- Phone... Installation will serve: Residence 5�- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms __Number of baths ---/- Lot size ----Ip 0------> �Z_.- - --------------- Water Supply: Public system J�L Community system ❑ Private ❑ Depth to Water Table -�4 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adob/e�-g Hardpan ❑ Previous Application Made: Yes ❑ No',2�--New Construction. Yes ❑ No ❑ R-- TYPE OF INSTALLATION AND SPECIFICATIONS: o septic tank or cesspool permitted if public sewer is available within 200 feet.) p is Tan Distance from nearest well-----------------Distance from foundation--------------------Material--------------._---___.______...___-____--_____. y..-� No. of compartments-------------------- -----Size---------------•--------•------Liquid depth--------------------------Capacity-•------------ al ° _ Distance from nearest well-----------------Distance from foundation to nearest lot line_______-. ______ � � Number of lines----------- ------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length____-___.____________--_-____________-___. See a e Pit: Distance to neare t well__tiQ1�-�.___Distance from un anon-_�.p_'_______-Distance to nearest lot line- Number of pits__________________Lining material Size: Diameter- ��---.----Deptlr �__ --_ Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material------------------------------------- ElSize: Diameter----------------------------- --------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------_----- -----------------------------------Distance from nearest building___--.-_____________-_________.__---_---_. ❑ Distance to nearest lot line- Remodeling and/or repairing (describe):---------------------------- ----------------------------------------------••---•--------------------•----------••---...- --------------------------------------------------------I--••------------------- ----------------------------------------•----------------------------------------•-----------------------------------•----------------------- hereby certify that I have prepared + is plicat.on a d that + work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regu s of It S oaqu n cal He Ith District. [Signed}--------------------------------------------- ----- �[[1l Contractor) BY: ------ --- - -- ---- -- ----(Title} ------------------- (Plot plan, showing size of lot, location of system in rel ion t e i dings, et , an be pl cad on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------- DATE-----------f- REVIEWED BY ------ DATE-- ------------ ------------------------------------------ BUILDING ----------------- - ------ PERMITISSUED--------------------------------- ---- ------ - -- I------------------------------------------ DATE-------------------- Alterations and/or recommendations:--------t------------------------------------ -----------------------------------•--•-••----------•--------- ...... ----------------------------------------------------•------------ -------------------------------- -------- -------------------------------------------------------------------------•---.....---------•-------------------- ---------------------------------------•-•---------- ------ - ----------------------------------------------- --------------------------------------------------------------------------.---------•------- FINAL INSPECTION BY:----- --------------------------c I---------- 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 ; IRevised W-2100