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APPLICATION FOR SANITATION PERMIT Permit No. q. (complete in Duplicate) - Date issued ------ it to construct and install the work herein described. made to the Son Joaquin Local Health District for a perm Application is hereby This application is made in compliance with County Ordinance No. 549. --------------------------------- -------------- 0—- --- --------- ------ ---- --------- 6 JOB ADDRESS AND LOCATION - -- ------------------------ Phone-----W ------------------------ Owner's Name-------------------------------- ------------------ ------ -- --- - ----A Address----------•------------------------------ - ------------------------•--- ---- Phon Contractor's Name____________________._.__------- - ---------- 0 Motel El Other 0 Apartment House 0 Commercial ❑0 Trailer Court Installation will serve- . Residence bedrooms Number of baths ------/_ Lot size ---- -------150 ----------- Number of living units: ---/--- Number of 6 Water Table Water SuPpIY: Public system X Community system 0 Private 0 Depth 0 Clay 0 Adobe$ Hardpan 0 Character of soil to a depth of 3 feet'. Sand El Gravel [] Sandy Loam [I Clay Loam [I New Construction: Yes [] N El Previous Application Made- Yes ED NoPr_ 0 TYPE OF INSTALLATION AND SPECIFICATIONS: vllabwithin 200 feet.) .....A- J4 X- ------ ----- Lvu" (No septic tank or cesspool.permitted if public sewer is Seafrom Material-------- ---------------------------------------- ------------Distanfoundation---- --------------- Capacity--------- f'Ic Distance from nearest well__________ ments -------------Size--------------------------------Liquid depth__.____--------------- -- �44&11tt No. of compartments..---- fro L f I t'on -_Distance to nearest lot line---- _Disfance rn ounc E�Tj ---- -- _.- fj Distance from nearest well-9MMA-1 49�7 ------------ _Width of trend}_ ------------- isposal Field: -------r-------Length of each line__ - --- I ------------ Number ol lines---- --------------Total length----- -0--------- ------- Type of filter,material Depth of filter mafe ------ ..... .,nearest well_.j6W%_%--------Distance from foundation__a,,�---------jistance to nearest lot IV Distance to r -----------9.11---------Depth--- ------------------------ Seepage i . Number of pits---I-----------------Lining-- materiat4&&VJ$------ Size: Diameter______-_in'ng --------------------- j from foundat�on------------_ -.-.L i Distance from nearest well ------gals. welL________________Distance Cesspool: ---------------- -----------------------------Liquid Capacity-__f----------------- El Sizo: Diameter---------------------------------I----Depth-----------------------Distance from nearest building---------------------------- ----------- -------- ------- ------------ Distance from nearest well----------------- - ----------------------- ----------------------- Privy' Distance to nearest lot line----- -------------- ------------------------------ -------------------------------- ---------------- F1 I I - - ----------------------------------------------- - -------------------------------- ------ Remodeling and/or repairing ( escribe):-- ----- ------- --- ------ --------------- --------- ----------------------------------------------- ----------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ------------------------------------------ -------------------------------------------- -----------------------------------------------------------I----------------- --------------------------------I------------ -- ------------------------- --- ---- -------------------A------------------------------------- d that the work will be done in accordance with San Joaquin County I hereby cert- at I have p- aced this application an I Health District. ordinances, State lap, a�nd�r-ves regulations o he San Joaquin Local Contract ( or) Signed)------------- --- ---- -----------------(Title) - - -------I------------- By:---------------------------------------------------- uA Ings, etc., can be laced on reverse side). (Plot plan, showing size of lot, Joe tion of syste n rel tion a w S, DEPARTMENT USE ONLY - -------------- ---------- DATE------- ---- ------------------a--------------------------_-- APPLICATION ACCEPTED BY----------------------- �- DATE------- --------- REVIEWED BY--------------------------------------------- DATE-------------------------------------- -------------------------------------- - - - B--U---I-L--D---ING----P--E--R--M----I-T-- ISSUED-------•---------------------------------- Alterations S--S--U---E--D--------------.-------------------------------------------I------------------------- Alterations and/or recommendafions:---- -------- ---- ---- -------------------- ----------------- ---------------------I------------------------------------------------------------------------------I--------------------------------------------------- ------------ ----- ----------------- ----------------------------------------------------------------------------------------------------------------------I------------------------------------------------------------------------------- ---------- --------------------------------------------- I Date-- ------ -------- -'-_-1----------------------------------------------------------------------------------------------------------- ------------- - FINAL INSPECTION BY:-.--------------- -- --- -------------- ---------- SAN JOAQ'UIN LOCAL HEALTH DISTRICT 814 North "C" Street 130 South American Street 3oo west oak Street 132 Sycamore Street TracyCalifornia , Stockton, California Lodi, California Manteca, California FS-9-2M 10.52 Revised W-2100