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APPLICATION FOR SANITATION PERMIT Permit No, ------ (Complete in Duplicate) Date Issued Application 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 Cou fy rdinance No. 549. B_ JOB ADDRESS AN �LOCA BION-- 11� -----------------------------------------------it------- ----------------- P.-i ---C? ------------- ------ -------------------------------------------- Phon`b#v,_� Owner's Name- -- ----e... Address--_ �Z�_ -- ----------------------------------------------------------------------------------------------------------------------------- -------------- Contractor's ------------- -------------....... ........ k Contractor.s Name---- ----- -- I ---------------------------------------------------------------------------------------- ----------------- Phone_--_------------------- Installation will serve: Residence Aparfent House [] Commercial E] Trailer Court E] Mof!� E] Other. ❑ Number of living units: 'Number of bedrooms Number of baths ___/___ Lot size S >-------- ------------------------------------ Wafer Supply: Publiclsysfem �_communify system E] Private Ej Depth to Wafer Table -------- ft. Character ofioil fo a depth of 3 feet: Sandi Gravel E] Sandy Loam Fj Clay Loam E] Clay [] Adobe <ardpan n Previous Application Made: Yes.0 No 2/ New Construction: Yes 2-'No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if ublic sewer is available within 200 feet.) Se nk: Distance from nearestw ----JL_ rom ------------ ... e4 __7�,__ ,,tabce,f f ol tion-10��M f r i --------- jze;L-......... No. of compartmenIs 31 - -------------- aT 1�x 19 4_.......Liquid dppfh__.�----- T T-------------Capacity------- D;s I/ '-�e from a 11 n Ce posa Field: Distan -om ne n from foun( istance to nearest lot I- C45 lin - ---------- �-N U-M ber of lines------------1----I- --------j-1engfh of each line------__-. _ - �t 0 ��t wel . foundation.! of filter I f�e--P Width of french------ --------- T --- Depth of filter material--------- --Total lengt --- ype Seepage Pit: Disfance to nearerr_w__ej .. ....... uUistance trom.foundafi(;n,.__.---------------Distance to nearest lot line______----- r -ne -materia---------- ❑ Number of pits-------4------ ------- Size: Diamefer-----------------------Depth-.----------------------- --- Cesspool: Distance from nearest well__ -------- Distance tion!%-- �m j8unda' material__---_._-____.___-.--------_------, �ize:-Diamefer - - ------ - IDepfh---------- -- %I - - Liquid Capacity-------------------------.--gals. Privy: Distance from nearest well_________________________________:_________.___ - Dista;ce f nearesf�ffa_1din4._'!! ❑ Distance to nearest lot-line- - -------------- ----------------------------------------------- ? -- -------- -- -------------------7 Remodeli p.6 a /or repairing (clescribo):------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------ - - - %_ --------------------------- ---- ---------------------------------------------------------------------------------------------------------------------------------------------------11------------------------------------------------------------------------ -----------------------------•------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin C.u-.t, ordinances, State laws,dfi-4 rACiind regulations of the San Joaquin Local Health District. (Signed)........... -----------------------------I- ------------------------------------------------------------------------(Owner and/or Contractor],'4�N By:6�------__..............--------------------------------------------------------------------------------------------------(Title)--------------------------------------------------•---------- -- _ '` (Plot -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY rNm APPLICATION ACCEPTED BY ---- ----------------------------------------------------------------- ----------- DATO�------------------------------------------------------ REVIEWED BY------------------------ - DATE- CBUILDING PERMIT ISSUED--------- ---- --------------------------------- •------------------------------- ------------ DATE--------r-------------- ------ --------------------- Alterations and/or recommaQdAiLons ..........1-4-.,r.__:___�.... ----------- ------------ --------------------------------- --- --------- ,--------- - --------- --------- ................... ---------------- --------------- - --------- 7- j?�,A�--- ------------ ------- -- ------------------------------------------------------------------- ------ ---------------------------------------------- ------------------------ ----------- I------ ------------- ----- ...... ------------------------------------------- .......7 ---------- FINAL INSPECTION BY%_:-AJ� ------------------------- ------- Date--- -------- ---------------------------------------------------------------- '1AN 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 E5-9-2M ; '-,Revised W-2100