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TIIP (si APPLICATION FOR SANITATION PERMIT Permit No. ._.Y?7��----- � `-- (Complete in Duplicate) 1__SDate Issued ___ Application is hereby made to the Sen 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. JOB ADDRESS ANDiLOCATIION------ - 4 --- ------ --------------- . -G------- �_ ------------- Owner's ----- Owner s Name------------- r •------- -------= ---:- ---------------"---:--------------------... P hone ----------------------------------- - �-- - _ �U ?Address--------------------------------•-----------------------------.-�-1--�----C--/----7----c--`--f-------�CJ C-'I-F -4--------------------'- ----------------------------------------------------------------- Contractor's Name ------ -------- ' -------------= --.. Phone Installation will serve: Residence;54 Apartment House ❑ Commercial ^E] TrailerCourt-0 Motel ❑ Other ❑C Number of living units: ________ Number of bedrooms _ `. Number of bathsl _ Lot size�______.__ _/. _ _�'.r-_�__. __------------ J W ter c / ' -- a Supply: Public system ❑ Community system ❑ Private R Depth to Water Table-.___-_-_ ft. Character of soil to'a depth of 3 feet: Sand [:] Gravel ❑ Sandy Loam [I Clay Loam El Clay E] Adobe Hardpan El Previous Application Made: Yes 0 No ❑ New Construction: Yes ❑ No # TYPE OF INSTALLATION AND SPECIFICATIONS: r f (No septic tank or cesspool permitted if public sewer is available within 200 feet:) Septic Tank: Distance from nearest wellDistance-from foundation l_f n?__._ .Mat rial-----------------------------------l ----- No. of compartments __.--------- ......Sizer.-, ------I---Liquid depth__..____ ..-� ---Capacity-_-----�3c�----- Disposal Field: Distance from nearest well...��__._Dist!nce from foundation-7i�'-�_ __ -.Distance to nearest lot line_______:'_._ Number of lines____le"-___.7—________________Length of each line_____�___. __�-1.. of trench_._._____. 2- - _ . r�_ - --.___ Type or filter material_ _ p g ' t-��-0e nth of filter material____._____�r��---Total length �-�_�_.___._ \ t p, g I from foundation---------____'____..Distance to nearest lot line-____.____.._____ __,______Linin "fer i Seepage a Pit: Distance to pneares ewe - -----� 9 Distance 1�ial_______________________Size: Diameter------------------._._IDepth____------------------------ ----- Humber of its_____________ g Cesspool: Distance from nearest weil4-e_.---___----Disfance from foundation____________________Lining material------------------.._____.___________ ❑ Size: Diameter-l--t..A----------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. ' ~ Privy:_ Distance;t ,�rom:nearest well--- ----------------------_-------- ----Distance from nearest building_'___._.___.__.___._______.-__________._._. ❑ Distance to nearest lot line ------------------------------- ----------------------------------------------------------------------------------------- :. y r 1 Remodeling and/or repaing,',(dasc'ibe): = ---------` -------------------- ----------- --------- Ut f -------------------- --------------------------------------- ----------- ------------------------•---------- ---------- -----------_____ _________________f.________ __.__--_____-_____________-_--__4 ' _____.___--.____________.-..______-___.,___________________-_____. __ -___________...__._________._._________._-__ 4 1 6reby certify,that l'have prepared this a`pplicc tion and that the work will be done in accordance with Sari Joaquin County ordinanceso:Stafe'laws, and rules and regulations of the San Joaquin Local Health District. I ( {Signed .----- X11 g �)•- --- - - - - -- --- --------- - - -- ----- ------- - -- - -- - -`��---------•-------------------------- -----(Owner and/or Contractor) gy�' �. • 'ate 1 (Title) ' -- --------------------------------- -------------------------------- (Plot plan, showing size of lo't, t, location of sysfery in relation to wells, buildings, etc., can be placed on reverse side). r �% i FOR DEPARTMENT USE ONLY I APPLIC.. ATION ACCEPTED BY___..- ;f�----- ---------------------- -----------------------------•------------- DATE------- ---�-� �--;�--�-------------- REVIEWEDBY-------------------------------------- # -------- DATE------------------------------------------------------------ BlJILD]NG PERMIT ISSUED '-.# ... - DATE. Alterations and/or recommendations��/- "�= R .. / ., �'---.�:?. _•� - �f=sem^---¢-- - - --�- -----••--------------------------- --------------------------------- --------------------------------------------------------------------------------------•--------------------------------------------------------------- ------------------------------------------------------------------------------- ---- --------------------------------------------------------------------------------------------- ------ ' --------------------•-----------•- ------ ----------- - --- ------------------------------------- ---------------- --- --- -- --- FINAL INSPECTION BY:. '_. .1-- --------------�- ..� Date ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 134 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-2M I0-52 Revised W-2104 s