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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application 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 oun i w compliance t"Cii-clioan'ce No-! 549. e ��4_e-�_ ------w.;71......... JOB ADDRESS AND-L9CATI0N_ --- ---- ----- --- �_� ._--_.. t'�- _- ------ Owner's Name------- ---------/. _M� E, - ---- .4------------ hone- Address--------------------------k-7n---t ....... - Contractor's Name----------------------- --/11-A-------�. ------------------------ Phorie — y------------------------------- Installation will serve: Residence F] Apartment House E] Commercial E] Trailer Court E] Motel E] Other,9. Number of living units: Number of bedrooms .-1----- Number of baths size Lot s V I--- "-%----------------- Water Supply: Public system ❑ Commt;nity syst6m" private Depth to Water TaloleA4.0 ft. Character of soil to a depth of 3 feet: Sand E] Gravel ED' Sandy Loam E] Clay Loam 0 Clay [] AclobeA Hardpan E] Previous Application Made: Yes E] No X, New Construction: Yes [] No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se is Tank:, Distance from nearest well-----------------Distance from foundation--- ---------- I------Material--- -- ------------------ -- ----------------------- -- No. of compartments----- - ---- - ----------Size--------------------------------Liquid depth------------ ---- --------Capacity----------------------- Woline_______________. -W al Field: Disfance from nearest well_________________Distance from foundation------------:-------Distance to nearest lot line------ -----------Aj Number of iines----------------------------------Length of each line---------------------------r--Width of trench---------------------------------__ Type of filter material___-____________________Depth of filter material-----------------------Total length_-__--__-_____.______________-________--. Seep e Pit.- Distance to nearest well__/,Zr R______Distance from founclation-_A6 Dito pp o nearest lot line-14--------- Number of pifs__0).'1A—_ - -Lining material--- 1-6-K.Size: Diameter_ -------Depth- 01 Z—_e------------------ Z ---.-' rgz 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--------------------------------------- F1 Distance to nearest lot line--------------------- -------------------------------------------------------- Remodeling and/or repairing (describe) --------------------------------- .... ----------- ----------------------------------- ------ ---- ---------- ------------------------- --------------------------------- -------------a� � .. 1. ------------------------------------------------------------------------------------------------------ ---------------------------- ------------------al---------------------en-----------//-------------------- V ----------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- ----- --- -------------- -------- I here6y certify that have prepared this application and that the work will be done in accordance wifh,;� an Joaquin County ordinances, S e-aws, and rulei4nd regulations-of the San Joaquin Local Health District. S\1 ------------ (Signed)------ ----------------- - '-------/---------------------------------------------------------------(Owner and/or Contractor) -WA/5- By:----------------------_-__ Z-.----------- -------------- --------------------- ------------------------------------ (Plot ------ (Plot plan, showing size of 1o4. I cation of system in relation to walls, buildings, efc., can be placeh/On reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ ------------ - -------- ------------------------------------------------------------- ------- DATE.5;:-—-------------------------------------------- REVIEWED BY----------------------------------- ... . ---------------------------------------------------------------------------- DATE__- --------------------------------------------------- BUILDING PERMIT ISSUED------------------------------------------------- ------------------- --------------------------- DATE-----` � ---------------------------- - Alterations ATE------ Alterations and/or recommendations:-------------------------- .........._--------------- -----------------------------------------------(S------•-------------------•------------------- ------------------------------------------------------------------------------------ ------------------------------------------------------------------ --------------------------------------------------------------------- -------------I------ -------------------------------------------------------------------------------------I------------------------------------------------------------ ----------------------------------------------------- --------------------------------------------------------------------------- -- ------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------- --------------------------------------------------------------------------------------------- FINAL INSPECTION BY-------- ----------- Date------ --- --------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M �0-52 Revised W-2100