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APPLICATION FOR SANITATION PERMIT Permit No. (Complete 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 compliancewithCounty Ordinance No. 549. JOB ADDRESS AND LOCATION---_,l -f ---?------ - Owner's Name - _ --- --- ------------------------ ------------- ------------------------------ Phone - 7-•---•---0' ---- --* or., `�" a a-� ------•----------------------•----------- -----------••---------------- Address-------3-- Contractor's Name. ---------------------------------------- ---------------------------------------• --•------- Phond5—. --�v--�- ' Installation will serve: Residence ,I 4 -*5ertment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units. _1--- Number e bedrg�m EV�Atit t 1dm erf of h$is5 �+ � ci,a IrPL ur WLLLIPUMP WUR : NLW WLLL PUMP INSTALLATION � SRYSTETMM REPAIR ,i- U SpnOTHER LJ 1 .W,F.ln.j -L.aat�jaY� �r4�KrGcr: Ion❑ SFL-�F&8, F Jariay'Loam UEI l..laAI Loam u c�1dyPff Alc�obe�Tardpan ❑ Previous Application Made: Yes ❑ No,—New Construction: Yes 9--444—D TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wellaryr ,,_Distance from foundation--- a-_....Material_---_ .__-- ---- -- ----------- �}� No. of compartments-------�-----------Size-- G-__x. - -----Liquid depth--,15-------------------Capacity__P?-------------- Disposal Field: Distance from nearest wello2%v,._ _Distance from foundation-- -. P 0-_-__.-.-Distance to nearest lot line---- �-- Number of lines-------/---------- --- Length of each line----- -----------Width of trench._2___5/.-!'-_-.----_-------_--- T e of filter material---- � yp , ---r...........Depth of filter material----f_e.--____-_Total length----- --------------------•---- Seepage Pit: Distance to nearest --------Distance_frorn�fo}�ndation.._..r o_'--.Distance to nearest lot ------- Number of pits------/-.............Lining material-4 _-.-.Size: Diameter--- ---------------- ' Z_ 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, Stafeaws, and rules regulations of the San Joaquin Local Health District. (Signed)----------- --- 4. --•---•--- ----- ---------------I----------------------------- ---------------------------------------------------------------------. r andjur Contractor) BY: ----------------••--------------- (Title)- (Plot pian, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------------------ -------------------------- DATE REVIEWED BY------------------------------------------------------ -- - DATE---- BUILDING PERMIT ISSUED--------------------------------- --- ------ .-.------------------------------ --------- DATE:-------- Alterations and/or recommendations---------------------------- ----------------------------------------------------- ' r--------------- -------------------------------- ----------------••---•-----•--------------•--------••----------------------- --------------------------------- ------- — 6" �- ------------------ ---- - -------- -- s --- ------- ..........t%........ ------------------------ ------ --- ---------------------------------- ----------------------------•-•--- ------------------- FINAL INSPECTION BY:-------- ----------------- - -- --�- - —} -----------------------•----- Date- -------�'-_-v.--�-�-,�_..--------------------- ------------- 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 l,4PPq5 AYWCOP 12-54 dh