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APPLICATION FOR SANITATION PERMIT , (Complete in Duplicate) Permit No. 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. JOB ADDRESS AND LO TION------- /----------- MP_R) /SON Owner's Name ---------- ----------------------------- -------- ---- Phone_%-~_.:Uld Address-----------------_-------- ------ -.:z----- 1-------------------------------------------------------------------------------------- ----------- Contractor's Name-------_-lt_tiv [,51 __ _.. -Al _�------------------- - --------------------------------------------- Phone_l Q` j�l G'7 Installation will serve: Residence ❑ Apartment House � Commercial ❑ Trailer Court [:]Motel ❑ Other ❑ Number of living units: _'��_. Number of bedrooms ________ Number of baths __ Lot size --- *47- _7a _,___________________________ Water Supply: Public system K Community system ❑ Private ❑ Depth to Water Table-5449'ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AclobeM Hardpan ❑ Previous Application Made: Yes ❑ No [�L 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: acr Distance from nearest we!! ----------------- Distance from foundation___________________ Material ___________.____-__-..-_____--_______---___-_. 4 E%1SNo. of compartments -------------------------- Size -------------------------------- Liquid depth -------------------------- Capacity..... ------. ---------- Disposal FieldK& Distance from nearest well_________________ Distance from foundation -------------------- Distance to nearest lot line ----------- ...__. ❑�1(1S� Number oflines----------------------------------- Length of each line ------------------------------ Width of trench ----------------------------------- Type of filter material ------------------------- of filter material -------------- .-------- Total length ------------------------------------------ Seepage Pit: Distance to nearest welL�kL�rrer--__Distance from foundation___.�.�*-_____-.Distance to nearest lot line ------------ Number of pits__CIi��---r----Lining material __�ii12CJKoo__Size: Diameter___ - 4- - woo .r._.___.__Depth_____.2--.5 ----- ------------ Cesspool: Distance from nearest well----------------- Distance from foundation ------------------- .Lining material-_--__._---._______._________________. ❑ Size: Diameter -------------------------------------- Deoth-------------------------------------------------- Liquid Capacity ---------------------------- gals, Privy: Distance from nearest well ------------------------------------------------- Distance from nearest building __________-_.________________.___._-.-._. ❑ Distance to nearest lot line ----------------------------------------------------------------------- ---•----------------------------------------------------------------- Remodeling and/or repairing (describe)------------------ - ----- ------------ -----------------------------------------------------•-----•-••----------- ----- •_-- __-- - - t, _ -------�--R' .[i TIF/-------eA"'- --------- -------- ---- -------- - - - - ----------------------------------------------------•-----------------------•------------------........------•---------••li(/--_------•-•-----------------.-_-- hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules n$ egulations o . he San Joaquin Local Health District. --- ---- r -- ------------------------------- Owner and r Contractor {Signed)--------------------------------- ----- - ( By: .............. ---------------- ----- -1 '----------- - - - - -•----(Title)----- Plot tan, showing size of of, location of system in relation to we[K, buildings, etc., can be plac� an side),' { P FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----,,�._ DATE y REVIEWED BY ------------------------------------------ --- - ---------- DATE---------- ----� ----------------------------------- --- ---------- ---------------------------------------------- BUILDINGPERMIT ISSUED---- •-------•--------------- ------ -i�- DATE--------------------�t----------------------------- Alterations and/or recommendations------------------- ------------•---------------------------------------------------------•---- - -- --••' ---------------------------------- I - --------------------------------------------- - ----------------------------------------------------------------------------------------- ------ I --- ------------------------------------ ------------------------------------------------------------------------------------------------------------- -------------•------ FINAL INSPECTION BY:----- -------------- ------------• Date------ -- ---------------------------------------- 130 South American Street Stockton, California ES --4-2M ; ' Revised W-2100 SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C' Street Lodi, California Manteca, California Tracy, California