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Permit No. APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) // Date Issued Application is hereby made to the Say Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in.weompliance with County Ordinance No. 549. 7I�23--Al--------- -----_-+��-+-= -----"'� --------------------•- --- JOB ADDRESS AND LOCATION--- } ---------------------------------------- Owner's Name__ 7__-Q.rr' a[s J, '' /J Phone_4„sr/ 7------- Address----- ------------- -----------------•---------------------------------------•--------------------•------- --------- ---•--- Contractor's Name-- �/' ".�''`�� --------------------------- -------------------------- --- Phone_�_ _ __4_Q.7------ Installation will serve: Residence (K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms Number of baths Lot size ---�,___ --------------- VWater Supply: Public system Community system ❑ Private E] Depth to Water:Table �®- ft. Character of soil to a depth of 3 feet;: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam_[] Clay ❑ AdobeX,b Hardpan ❑ Previous Application Made: Yes ❑ No �; New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: \ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) v++ Septic Tank: Distance from nearest well________________Distance from foundation--------------------Material---- --------------,by 494eVNo. of compartments-------------------------Size--------------------------------Liquid depth--------------------------Capacity ---- - ------- Di�� Field: ar nearest well-----------------Dta��efrea foundation--------------_._ Distance to nearest pt me ---7 - /_ Width .of trenc -------- ----Numbeof l neseno# each line------ __ Type of filter material____ ________________Depth of filter material------------------ ----Total length------------------------------------------ _______- ___-____ _________ --------- Seepage Pit: Distance to nearest well_ Distance from fours ation._.-.1to nearest lot line Number of pits----:____/-----------Lining material_____________ K Size: Diameter____ , -----Depth__5_jD_----____-_____________ Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material-------------------------------______. I ❑ Size: Diameter--------------------------------------Depth----------------------------- ------- --------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well.------------------------------------------------Distance from nearest building___________________-_____________________. ❑ Distance to nearest lot line--------- --------------------------------------•--------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe):-------- --------------.---------------------------------------------------• ------------•-------------------..... --------- ------• ------------ -------------------------------------=---- ----------------------------------------------•-------------------------------------------------------------•-------------------------- ------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rales and regulations of the San Joaquin Local Health District. (Signed]____02�__A e---- • __r ------------------------- (Owner-and/or Contractor] _ .- 4 By:--_!47 ----- '1 + x ---------------------(Title) ------------------------------------ (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 ' --' �- REVIEWEDBY----------------------------------- ---------------•------------------------------------------------------------------------ DATE---------------------------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------I---------------------------------- Alterafiohs -----------------'-=------------------------------------ Aiterafionsaci1d/or recommendations------------ -------------------------------------------------------------------------------------------------------------------------------------------------- - T ------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- � k ---------------------------- •--------------------------=---------------------- ---------------------------------------------------------------------------------------------------------------------------------------- 1 �3 _ ______________________________________________ ______________________________ -__________ __------------------------- FINAL INSPECTION BY: y ------------------ Date p -' ----------------- -------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT t130 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 8-51 Revised W-2100