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APPLICATION FOR SANITATION PERMIT Permit No. (Complete'in Duplicate) Ji Date Issued Applica-1-ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describdd. This application is made inporn liance.:wifh County Ordinanc'e No. 549. _! JOB ADDRESS AND LOCATION_.------ -------------- -------------------------- ------------- ------------------------- -------- ---------- ------------------------------------- Owner's Name------- -------- --------- ...... ----------------------------- -------- one---------------- --- Address---------------/X ----------------------------------------------------------------------------------------------------------------- Contractor's'i,N�a�.ne-----1---------------------------------------------------------------4------------------------------------------• i-------------------- Phone Installation will terve: Residence ['E�partment Housia 6' (Commercial [] Trailer Cc�u4 E] Motel [I Other E] Num Number of living units. Number of bed roAoms�_.l*Number of baths Lot size ---------------- f-IR---------------------------- Wafer'Supply: Public system Ej Community syst4m E] P iva te AO-t repf h to Water Table -------- ft. Character of soil-i to a depfh'of 3 feet: Saind E] G f ravel Sandy Loam [] Clay Loam Ej Clay ❑ Adobe Pr`Pardpan E] Previous Application Made: Yes E] No �ew Consteu'ction-.' Yes u�-<o rl TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic'fank*or cesspool permitted if public sewer is!available within 200 feet.) Sep is Tank: Distance from nearest well--e C -----------Di,talce from foundiiion----- ---------- ---N�aterial---- -------------- 'I -- No. of compartments-------Z*-------------size--- S-Tici,id cl,01-i--------0---- ---------Capacity------- 14 Disposal Field: Distance from nearest well---%r 4----Distance from foundation___ _-Q---4 -----Distance to nearest lot line___--____57- Number of lines:----------- Length of each line__________. ®_.___._._.Width of trench_______ ____ ___ `' _ �/N Type rench----- Type of filter maferial_.50i ------- C> )p6-f6i epfI4 of filter mater Pit: Distance tc;'nearest well----" -------------------Distance from foundation___________________.Distance to nearest lot line_________.._____ I __ El Number of pits-------=--------------Lining material--------------------- -Size; Diameter------------------.---..Depth------------------- - - -------- Cesspool: Distance from nearest well___.________.__Distance 3 -----------Disfalce from foundation---------------------Lining material----------------------------------- EJ Size. Diameter- ----- --------------------------------Deptkh --------------------------------------------------Liquid Capacity-- ------------------------gals. r Privy:1 Distance from - 1 neare'st,we]___ - ------ .-Distance from nearest building._ - - - !' ----------------------------PFJ Distance to nearest lot —------------$ .. -__---'-_-."4 _1-_d -------------------------_:--------------------------I-aww Remodeling and/or repairing (describe): ------------------I-------------- ---------------------------------- ---------------------------- --------_------------ - -------------------------------------------------------------------------------- - --------------I------- --------------------------------------------_------------ -------------------------------------------------- ----------------------------------- --------------------------------------------------I-------------------------------------------------------------------------------------------------------------------------------------- ------------------ ---------------=------ -- I--------------------- -------11----------------------------------------------------------------------- -- ------ - --------- I hereby certify that I have prepared this application and:�f hat the work will-be done in accordance with'SanJ_oa_quin...County ordinances, State laws.- and rules a d regulations of the San Joaquin Local Health District. (SignA/)__ -------------------------------------------- ----------- ---(Owner and/or Contractor) By:-------_------------ [ - - e - --------------------------- (Plot -------------------------------------- plan, showing size of lot, location �f system in relation to wells, buildings, etc., ca� be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ----- - ——---------------------------------------------------- DATE----- BATE--------- REVIEWEDBY-------------------------------------------- -------------I----------- -------------------------------- ------------- DATE -- --------- ------ J ---------- BUILDING PERMIT ISSUED------------------------ ------- - f/- - -------------------------- -------------------------------------- ----------- ---------------- ---------------- -------- Alterations and/or recornmindations:-------------- -- ---- -- ---------------------------------------------- --------------------------------------------------- 15'41 ;L+,X�t '4 V -—----------- jww --------------------------------------------------------- -------- .. ..... ----------- ........ -------Z------------- ---------------- Ilk ---- ------------------------- ----------- ---------- .......... 7g- A FINAL INSPECTION BY:.__,4 ----------------------------------------------------- --------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lod;, California Manteca, California Tracy, California ES-9-21A Revised W-2100