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APPLICATION FOR SANITATION PERMIT Permit No. ___0.. . (Complefe in Duplicate) Date Issued ____�__ Applica-�ion 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 County Ordinance No. 549. hh L JOB ADDRESS AND LOCATIO - ---21-0---------C` Owner's Name----li'� #'`r------ ---- ----------------------------------------------- ------------------ Phone-------------------------------...._ Address-- ---- --- - ------ - --- --- - ----------------�,---------------------------�_---------------------- Contractor's Name--------------- ---------- - -- ---------- .- ------ ---- ------------ Installation -----------Installation will serve: Residence ❑ Apartment House ❑ Commercialrailer Court ❑ \ Motel ❑ Other V---------- Water Supply: Public system [ r"Cammunity system ❑ Private ❑ Depth to Water Table _0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan El Previous Application Made: Yes ❑ No [ ew Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic.tank or cesspool permitted if public sewer is available within 200 feet.) +, Septic Tank: Distance from nearest weIILY--'�_Distance from foundation--------------------Material___ 4 No. of compartments----------/------------Size---- - -- ------------Liquid depth----%S........---------Ca paci ty..4�_o_o-------- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line----------------- El Number of lines-----------------------------------Length of each line------------------------------Width of french----------------------------------- Type of filter material_________________________Depth of filter material--------.--------------Total length_____._________________________:___---____ Seepage Pit: Distance to nearest welf_�'?^ __.Distance from foundation--------------------Distance to nearest lot line__j� ti,. Number of pits---- ___----------Lining material_ cy�+x.1____Size: Diameter_13-------------Depth_._ ---_____---_-.___ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material------._----_--------_-----__________ ❑ Size: Diameter-------------------------------------Depth----------------------------- ----------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well __________--------------------------------------Distance from nearest building__-------_--__--______________________- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------------ Remodeling and/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, 514le ]awl, and rules and regulations of the an Joaquin Local Health District. (Signed) -- ---------- --- --- --�'` ------------ ---------------- --------------------------- --------------- { er and/or Contractor] � ,.------- By:---•----•- --- - ---- ------ --- 4 = (Title) (Plot plan, showing size of lot, location of system in relation to wel[s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY _____- _._ DATE_ -:_....____. ------------------------------------ - REVIEWED BY------------------------------- ----- --- ---------------------------------------•------ ----•----•-•------------------. DATE----- --------------------------------------------- .BUILDING --------------•--------•------------------- BUILDING PERMIT ISSUED---------- -------------------------•---------------------•-----------------------------------------��ATE.- � Alt rations and/or recommendationN: .. -- x• -------- --------- ------- n-- -•---'-"�--- :<._._...---- �----- - --- ..---i`-�-�'4-- �._�s� . _. •---��- �.�.� =�--r---vim.- - --•--------• --------- --------------- - ---- ------------------- --------------- ------------ E --------------------------------- -- Y ------------------------------------------------------------------------------------------ --------- ------ ---° =------------2- Zo �,,,,,,�► - CaI-Ted__.Roto_..Hooter-and---theg_._reportea---Too-s-frig the---job to Parrish, who put in the system. t.f. FINAL INSPECTION BY--- -----------------•------ ---------------- ------------- Date------------------------------------------------ - SAN 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 ES-9-2M - Revised W-2100 1