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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicafe) , Date Issued :�_� Applica�ion is hereby made to the San(Joaquin Local Health District for a permi+ to construct and install the work her m scribed. This application is made in compliance with County Ordinance No. 549. I : JOBADDRESS AN CATIO -----------� - ----------- -------/.----�------ ----- ---- ==--=------------------------------------------------•---•--------.... Owners Name-----.- +� i!K- = " Phone--- _ --------- -I --------=-- Address_ ------------------•-- ------------- --------------- --- .......... Contractor's Name------ -- - ------- f ------------------------- --------- ---------- Phone---�/a Q '-4-------- Installation will serve: Residence ❑ Apar+ment House Commercial ❑ Trailer Courf ❑ Motel ❑ Other ❑ Number of living units: _ Number of`bedroomst3' Number of,'baths -.3' Lot size -------------------------- Water Supply: Public system ' Community;,System.El 'Priv�te 0, Depth-to'WaterTebie.�_O;ft_ Character of soil to a'depth o 3 feet: Sand ❑ Gravel.E] Sandy Loam ❑ Clay Loam ❑ Clay 0 •Adobe' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No-,.❑ TYPE;OF INSTALLATION AND SPECIFICATIONS------4 (No septic tank`or cesspool permitted if public sewer is available within 200 feet.) ep '-- Tank: Distance from nearest well , Distance from foundation Material-------------------------------------- --------- \ No. of compartments..........................Size +--- d� th Ca acity-------------- t1 Disposal .Field: Distance from nearest well------- Dis+anc`e from f&ncla+ion `) Distance to nearest lot line-----6____ -_- 44 Number of lines___:_!____ Length of each line._______ ff Width of french------------ Type of filter material._ c r 'Depth of"rf€Iter material__ 1- z-___.TotaI length_____________________ ______________ eepage Pit; Distance to nearest well___________ ___r^�iDistance from foundation__ _-_.____.Dist3,01 �nce to nearest lot line____________... 4 Number of pits.---- f --_- i Lining material_CC�G .Size:'Diamete'r--.__�I; Depth -----a- ----------------- . _ ,. s , # Cesspool: Distance fromrnearest weir ____ Distance from foundation___.__.____ _.Lining material____ _____________________________ N� _ Li uid Capacity -----`- `---gals. e [� Size: Diameter - ------------------ 4Depth ► fi ---- ----` - --- ---- - - Privy: Distance from nearest __. 1'��Distace'from riearest building r ________________________________ i F] i Dis+ante to nearest lot line �.. "_" .,----------------------------------.� --------------------------------------------- - ---- ----------=------�--- -y"----------- t I Remodeling and�or repairing (describe) *` ` f S � k ...-.- ----- ------ ---- ---t------- ----- - -- - - } i I hereby certify that I-have prepared fhis,applico,tron and fhaf_fhe work-will 1e done in-accordance with San Joaquin County ordinances, Sfate ws, and rules and regulations of the San Joaquin Local Health District.' E (Signed) 6 �-------------- ------------------------------ - _ � � - ,ner.and/or Contactor BY:---------- -- -_- ---------------------------------------------------- -- (Title} (PlotIan, showin size of lot, locafionof system in relation to wells, buildings, etc.,'can -lie laced on reverse side). ti ( P g. .. Y g , p, # FOR DEPARTMENT USE ONLY Y APPLICATION ACCEPTED BY--------- = # = DATE ?{• t ------------ -------------- = R REVIEWED BY------------` =------------ - DATE---------•:------------ BUILDING PERMIT ISSUED------=------------------------- DATE ----------- BUILDING arnd orRrecor►r ions:,,_.--•----.•-____-- - -f ..€ ";r _--.--• -------- --- �^ ---__- .�_�--�- -..................... r y t ______________________•_.____.___-_-- _ _. _.._.______..._____.__ ____ ___ ________________.-_______.___________________.. ..._____. ... _____ _ ____________ ________________ ----------------------------------------------------_..__.____`_ ____. ...............______._______.____.--______ i __ _ __________.____________._______._-_-______ ____ ____ _ ____---_____-------___-___ ___-___ T I -- 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