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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --- ---- q Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein describe. This application is made in compliance with County Ordinance No. 549. 'd JOB ADDRESS AND LOCATION- ----- - ------ ------ N_ Owner's Name____.__"W------ - --------- -------- Phone----- ---------------------- - -------------- -1--------------*�---------------------------------------------- Address------- ------06---- ----- ---------- Contractor's Name---------------------------- ---- --------------------------------------- --------------------------------------------- Phone----------------------------------- Installation will serve!. ResidencY Aprtm f House ❑ Commercial E] Trailer Court [-] Motel F] Other D Number of living units. Number of bedrooms __-r-_ Number of baths -__l___ Lot size _ -0------------------------- - Water Supply: Public system`❑ Community system [I 'Private ( Depth to Water Table *>D. ft. Character of soil to a depth of 3 feet: Sand [] Gravel 0 Sandy Loam E] Clay Loam [] Clay Adobe [] Hardpan E] Previous Application Made: Yes E] No New Construction: Yes X No [I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pu6lic sewer is available within 200 feet.) Septic Tank: Distance from nearest well--- -----------Dista e fr m foundation----/-,a-------- ---------- ---------- -------- Maferi 1____ --------- --�y -------Liquid clep. --- -------- Capacit partments---------- --------------."-.-Size__, _ A� ci No. of corn Disposal Field: Distance from nearest well-_Z017_Distance from foundation."" Distance to nearest lot I' e---,'------S--- Length of each line------ Width of trench-__- Type of filter material__��;_04,.Depfh of filter material--"-... __"---.Total length_-_____ �_..___ ___.•___._-._. Seepage ength-------- Seepage Pit: Distance to nearest well----"---------------""Distance from foundation_-"---_-___-_.-_"" Distance to nearest lot line----------------- I] Number of pits----------------------Lining material---------------------..Size: Diameter----.------------------Depth-_--------------_---------------- Cesspool: epth----- ---- ---------------------- Cesspool: Distance from nearest vvO-----------------Distance from foundation----------------.-_Lining material_-.._"_______"-"-.-_"-______..__.__.. ❑ Size: aterial--------------------------------------- Size: Diameter--------------------------------------Depth--------------------------------- ---------..PqyLid _Capacity___;,,,;----- --------g ad Privy: Distance from nearest well-------------------------------------------------Distance 'from nearest building.--.-.-._"-___"-_._______ ❑ uilding---------------------------El Distance to nearest lot line----- --------------------------------------- - --------------------------------------------------------------------------- ---------------- 7 Remodeling anvodll r repairing (describe): !�7�_ ------------------- --------------------- 24--4�e��-- - 4 le. rt-PI-A e t 11!� -------Z-t- jl!�2 14-f -------------- --------------i-------------------------------------- 0 131--------- ----------------�4_9 :-- -------W-------4-7--1--&-1— -A-----------:�L,7 ,r ---------- --------------------------------------------------------------------------------------------- I hereby ce%ify that I have plared Ais application and fha+ +he work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. (Signed)---------- --------d --- -- ------- --------- ----------------------------------------------------------- ---------------------------------------(Owner and/or Contractor) By:------------------------- --------------------------------------------------------------------------------------------------------(rif le)------------------------------------ -------------------------- (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 ti APPLICATION ACCEPTED BY---- Y------------------------------------------- ---- --------------- ---------•---------------- DATE --------- --------------------------------- --------------- D/ REVIEWED BY----------------------------------------------------------------- ----- -- DATE BUILDING PERMIT ISSUED--------------•---------------------------- _ - -_ ------------- DATE---------®--------------------- Alterations and/or recommendations:------------------------- .............. -----------------------I-----------------------------------------------------------------------f-------------- 1 11 ------------------------------------------------------------------------------------------- ------ ------------------------------------------------------------------------------------------------------------------------- --------------- --------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ,n rules and regulations ......... ..... .. j. ............... ......... ... ------------------------------------ ------------ ----------------- ---------------------------------------------------------------------------- ------------------------------------------ --------------------------------- ----------------------------- ------------------------------- --------------------------------------------------- ------- ---------------- -------------------------------------------------------------------- FINAL INSPECTION BY:. -- ----------------------------- --------------- Date---- ------------ -- ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "& Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100