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Permit No. APPLICATION FOR SANITATION PERMIT ...I------------- (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 compliance with County Ordinance No. 549. JOBADDRESS ANDOCATION......puj/----------- ------- - ----------------------------------------------------------------------------- Owner's Name_,,,,_��, . ........ .._`....--••----- --------------------- -------- -------------------------------------------- -—-_------------ Address----- ----------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------.__ Phone----- .......... Contractor's Name--.-- C Installation will serve: Residence x Apartment House E] Commercial E] Trailer Court [] Motel Ej Other [3 Number of living units: J__._ Number of bedrooms .2... Number of baths __/---- Lot size _X--- ------------------ ---------- Wafer Supply: Public system 9 Community system El Private El Depth to Wafer Tablft. Character of soil to a depth of 3 feet: Sand E] Gravel 0 Sandy Loam E] Clay Loam 0 Clay [] Adobe Hardpan E] Previous Application Made: Yes E] NOX, New Construction: Yes4No El TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) eptic T nk: Distance from nearest well_________________Distance from foundation--------------------Material------------------------------------------------ 9 No, of compartments-.------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Dispos I F1 d: Distance from nearest well-- --------------Distance from foundation--------------------Distance to nearest lot line____-____--_-_-_- ' Number ine----------------- Number of lines------------------------------_ Length of each line----------------------------- Width of trench----------------------------------. Type rench------------------------------- Type OT filter material--------------------------Depth of filter material-------------- -- .....Total length___.___________________________________-._ Se ---Disfance .�romf , Seeps e Pit: Distance to nearest well_ �---- $nclation---1-40........Distance to nearest lot line_____yt Number ine- ------ Number of pits._)---------------U,Mg material ._.__.Size: Diameter__„_____________ pth- Cesspool: Distance from nearest weil-----------------Distance from foundation--------------------Lining material_____..________-___._._______:_____- 0 r. Size: Diameter--- ----------------------- ---------Depth-f------------------- -----------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well__,_-____-_____.-----__--- `_-__,_----------- -Distance from nearest building.____.____.__._______-_---___..____.____. ❑ uilding----------------------------------------- El Distance to nearest lot line-------------- -------------------- ---------------------- ----------------------------------------- ---- ---—--------:-------- Remodeling and/or repairing (clescribe):--- - --- --------------e•------- -------------- ----------------------------------- ---------------------------------------------------- --------- --------------- --------------------------------------------------------------- .............. - - - -- -- -------------------------------------------- --------- -------------------- --------------------------------------------------------------- i,ing ---- -- -r'6 ...........des�--------- --------- ---------------------- --------------I----- - - --- ------------------------------------------------------------------------------------------------------------------------------------------- --------------- it I I hereby certify that I_1q, e prepared this application and 'that the work will be done iW accordance with San Joaquin County ordinances. Stat laws, and le -nd regulations of the San Joaquin Local Health District. (Signed}- --- ------ writer and/or Contractor) By:. (Title)------------- ------------ ---------------- er .. ....... ------------------------------------------------------------------------ 2 ' ...... _W --- ---- ---- -------------------------------------------------------------- -------- By:------------------ Y-6-2. -_ __ (Plot plan, showing size Of lot, location of system in relation to wells, buildings, etc.. can be place on r arse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- --- C~b ------ --------- ------------------------------------------ DATE---- -- ----------- REVIEWED BY --------------1---------------------------------------------- ----------- -------)------------------------------------- DATE BUILDING PERMIT ISSUED------------------------ --- -- -------------- ----------------------------- -------------------------------- --------- .. ---- ------D--A---T--E------------------------------ Alterations and/or recommendations:--------------�------------------- ---------- ----------------------------------•-------- . --------- - ----------------------------------------------------------- . . - ----------- ----------------------------- - ----- ----------------- ... -I-- ---------------------- ---------- ------------------------------------------------------------------------------------------------------------- ---- ----------- L ---- S . ._e- k --N- ------------------ --- --V _!t1-------------------------------------------------------- ------------------ i -- FINALINSPECTION BY------- �- ----------- ------ -------------- Date---.---------------------- --------------------------------•---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oat Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---9-2M 145446 ATWDDV IZ-54