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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued---------- permit to cons =�3'r District fora construct and install the work herein described. Thisapplication islemadea n compliance with County a0 Ordinance No.544. P ' ica-�ion is de to the San uin ------------------------------------- JOB ADDRESS AND LOCATION --- -7------------- ------------------------------ Owner's ------------Owner s Name-------------- -- - -- ---- Address-..-- ------I.... Phon�W47--- .---••--------------------------- , Contractor's Name-------------- -- -------- ----- -------- ----- -------- Installation will serve: Residence Apartment House ❑ Commercial E] Trailer Court F] Motbi ❑ Other El r y / Number of living unfits: _-. -: Number of bedrooms __ Number of baths --/---- Lot size .--�----4- 7 a------------------------__-_ Private ❑ .Depth to Water Table __d ft. Water Supply: Pub4ic'system �ommunity system 11Private. ,�,fHard an Gravel Sand Loam ❑ Clay Loam ❑ Clay ❑ l-7 p ❑ Character of soil to a depth of 3 feet: .Sand ❑ ❑ Y � Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: [No septic tank or cesspool permitted if public sewer is available within 200 feet.] Septic Tank: Distance 4from nearest well---------------- Distance from foundation Liquid de th --Mafierial_-----`---Capacity ❑ ' No. of compartments-------------- - ------ --Size------•-------=•- - = q P. ----------------------- No. •--------•----- ----- ce om Disposal Field: Distance from nearest well -----'Dengnh of reach lin -----------------------------foundation W dthcofttrenchest lot line -- -------`- Number of lines0) ❑� Type of filter material-_---__--- ------Depth of filter material----------------------Total length-------------;--Y--------------------------------------- ---------:---i N _ a. 0 Distance to nearest lot line-��------ ---•----- q rr ----------- o" „!y Seepage:Pi}; Distance to nearest well --- ----------Distance fro fou a#ion---_ --- .Dept'n---__ ,_ --- I Linin materials C_ ____________Size: Diameter-,—%.-- - _ - L�' Number of pits.. = f------ g Cesspool: Distance fiom nearest well---------------- Distance from foundation--------__----_'-_.Lining material--__----_----_.------_-_--_---ads. { ;:: Liquid Capacity- ------------------------•9 ❑ Size: Diameter--*#------------ -------------- ------------ .----Depth ' Distance from nearest building--___----------------------------------- --------------- Privy: Distance from nearest well----------------------------- _ - -_--------_----- 1 Mance to nearest lot line------------------------------- - -I ❑ r I ----------------- Remodeling and/or repairing (descrbe)------------------ --------•------------_--------__-------- ---------------------------------------- --==--------------------- ' -----------------------------•-----------------------------_----------•-------------------•--------------- tai i I hereby-certify-that I have prepared this application and +hat+he work will be done in accordance with San Joaquin County ordinances, State laws 'and rules anF d regulations of the San Joaquin Local Health Districts and/or Contractor) l � k (Signed) ' ---- --- 9 )------ ---- , ' -------------- ---------------------------------------------- By: {Titl -- --- -- ------------------ ---- (Plot plan, showing size of lot, loca+ion of sys+em in relation to wells, buildings, etc., can be placed on reverse side. l t FOR DEPARTMENT USE ONLY DATE--------- �� ---- -- ----------------- APPLICATION ACCEPTED BY-----=`--=---------------------------------------------- DATE - --•-- ---------- REVIEWED BY--•-------------------------------i---------- ----- ' ---=-------------------•--- DATE-------------------------------- ------------- •--'�-----•- BUILDING PERMIT ISSUED ------------------------------ ' ------------------ • - . Alterations and/or recommends+ions:------------------------- - - -------••--•--.------------------------------------- - -- --- -------- ------------------------------------ - --- -_------- ------------•------------------ -------------- ----•-------------------------------- ----------- --------------- ---------------- � . D t x -------------------------------- FINAL- INSPECTION BY:------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C” Street 130 South American Street 300 West Oak Street Trac California Stockton, California Lodi, California Manteca, California Y� ES--9-2M Revised W-2100