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APPLICATION FOR SANITATION PERMIT 'Permit No. IN [Complete in Duplicate) Date Issued 3 Y/1 Application is hereby made to the Satn Joaquin Local Health District for a permit to construct and 'install the work herei d. This application is made in compliance with County Ordinance No. 549. - "2 LO ATION____ ...... JOB ADDRESS AND, ----- ------- h AV. Phone.-- one---- _�. ....... . Owner's Name- --------------- ---------- ----------- -----------------------------------le ------------ -------- ----------------- ------------------------------------------ Address----------------------- Phone./!9 7-------1702---- Contractor's Name_-___-_----------------------- --------------------------------------------------------------- --------------------------------------------- Installation will serve: Residence�Apartment House El Commercial [] Trailer Court 0 Motel 0 Other El Number o baths _/---- Lot size --- ----------------------- Number of living units: ___k�'Nkimber of bedrooms zvf—I- Numb ;-- ---- Water Supply: Pubiic-sysfem 'r] Community system El Private ��Dcpth to Water Table Character of soil to a depth of 3 feet: SandGravel Ej Sandy Loam El Clay L am E] Clay E] Adobe 0--Hardpan P3"", _ Previous Application'Made:-Yes [I No EE" New Construction.:--y s. N TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available wi#hin 204 feet.] Septic Tank- Distance from nearest well________________Distance from foundation-------------------Material--------- ------------------------ ------------->� --------Li quid depth--------------------------Capacity----------------------- ------- 0 No. of compartments-------------- ---------Size------------------------ ------------Distance from foundation--------------------Distance to nearest lot line--- - --------- Disposal Field: Distance from nearest well...... Width of trench- ------------------------------------- Number of lines------------------ -----------------Length of each line----------------------------- r Total length------------------------------------------ Type OT filter material------------------------Depth of filter material--------------------1-Total Pit: Distance to nearest well------/0-0-f---Distance from fou ation----- Distance to nearest lot line__._ -------- Lld Number of pits.......... -------Lining materialA�Z_q_iP----------- Size: Diameter___a-�--- Depth Cesspool: Distance from nearest well-----------------Distance from foundation---------------------Lining E] material__._---_-________.__-______.:_____._ ----------------�7------------ _,.��:_Dianneter----- ------------Depth-- bld --- gals.. -------------------------------- - - Privy: Distance from nearest well_________ ____________________ Distance from nearest uiing-- 0 Distance to ndarest.lot line---------- ---------------------------------------------------------------------------------------- ----------- 4- 2 ------- ------ es<,ri e):-- Remodeling and/or repairinghd -- - - ---------- q----------------------------- --- -----Cr ------------ ----- --------------------------------------- ------- ------------------------- -------- ----------------I--------------V�-------------------------------------------------------------------------------------------------------- ------ --------- --------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law nd rules and regulations of the San Joaquin Local Health District. - --- 777:?�(Qw#wi-�ind/or Contractor] ------------------------------------ ------------- --- -- -------- ------- ------------------- ------------------- (Signed)----- -------------- ----------------(Title)-------------------- ------ -------------------------- By--------------- ------- -------------------------------------------------------------------- (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__ ATE--- ------ --------------- -------------------------- REVIEWEDBY------------------------------- - --_1--------------------------------- --- -------------------- BUILDING PERMIT ISSUED-------- ------------------------------ - _ - -------------------- -------I----------- DATE - --------------------------------------- Alterations and/or recommendations---------------_- --------------------------------------------------------------------------------------- -.1------------I----------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------- ----------- ----------------------------------------- ------- -- -------------------------------------------------------------- ------------------------------ -------------------------------------------------11- --------------- ------------------- ---------------------------------- ------------ - ------------------------------------------------------------------------------- ------------------------ ---------- --------------- -------- --------I-------- ---- ------------------------ --------------------------------------------- ---------- )------------------ -------- Date..... FINAL INSPECTION BY:- -- ---------•----------------------- L=_AU_ 57�_ �AV Ul tT HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, Cal;fornii- Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100