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APPLICATION FOR SANITATION- PERMIT Permit No. ..... II (Complete in Duplicate) Date Issue application+2J is hereby made to the San Joaquin Local Health District for a permit to construct and install e ork herein .6scri ed This application is made in compliance/with County Ordinance No. 549. 0 ZZ JOB ADDRESS AND LOCATION--- A ----S;4z.-j - - -------- ----- --------- - ------ Owner's Name-----------------------m------- M_ ",!Z6_V------- ----------- Phone------ _ U---------- - r ------------------------------------------- 2 -----------S; [ ------------------------------------------------- ----------------------- ----P-7---/ ---Z:) . Contractor's Name-------------------------- - ------------- ----------------------------------------------------------- Phone.... ..7�!,fz'I -- --------- Installation will serve: Residence Ej Apartment House [-] Commercial Trailer Court E] Motel E] Other ❑ i. Number of living units: -------- Number of bedrooms -------- Number of baths�---- Lot'size 20_:re1t4_ .... -------------j ---------- Water Supply: Public system Cg Community system [] Private E] Depth to Wafer Table _4_0 ft, Character of soil to a depth of 3 feet:; Sa4�6_lnd Ej Gravel E] Sandy Loam [] Clay Loam E] Clay Of Adobe Hbrdpan [j 0� i Previous Application Made: Yes M No E] New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-AP-AE----Distance from foundof'o -J!5 _.Ma'terial----- ------ ---------- o"IT --- -- --------Capacity__/A0j9_'?,"_No. of.corn pa rtmenf s--cR---- - - ------ ---Size clep�h--- ' I - ;7o-I I - a, Disposal Field- Distance from nearest well ----------------Distance from foundation--------------------Distance to nearest lot line----------------- Number-oHines-----------------------------------Length of each line---------I---------I--------.Width of french-_--_---:.7-----11---------- g ""� Type .7------11----------,Type or filter material--------------- Depth of filter materiaJ-----:�---------------Total length - --------- ---------------- ------------- Seepage Pit: Dlista �ce�fZ nearest well-lib-NE-----�_Disfance from founclation____,14�..___.Distance to newest I t line. Number 8Diameter_____! -i-W-1f ofpifs its--____/_____.------- --Linin ----- g materials dj----Size: --- --------------- Cessp'081:'1 Distance frominearest well_- _il[�istance from foundation--------------------Lining material-,_---�------------------------------ El Size: Diameter-----------------.- ,-- ---- Depth------------------------------- -------------------Liqluid Capacity 11 ---------------------ga Privy. Distance from nearest well.____,_----------- ----------------------------Distance from nearest building-- ------ -;_.______J-_____._____-__i f;T I ------------- llc�. El Distance to nearest lot line._.___._.___ - ------------------------------------- --------------- ----- ---------------- � = ,7f-.- Remodeling and/or repairing (describe): _d4�-------ey2g.2(1---I ---- C_ -------------------------I..40---------- ------- ------------------------------------------ ------ -------------------------------- -------------------------------- ------- --------------------------------------------------------\--------------------------------------------- I.?-----------------I------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ - Vliiefeby�c�rtify th9d) have prepared this application and that the work will be done in accordance with San Joaqu'in County ordinances, State laws.Wdd rulesand gulations of the San Joaquin Local Health District. . ...............7 Z, (Signed)-.- -------- ------------- -------- ---------------------------- ---------------------P"Mmaalw on rac or By:-------------------------------------------------------------------------------- (Title)-----C.3- _i_m_ - 0- 1 ------------------ ----------------- gs (Plot plan, showing size of lot, location of system in rela to wells, build* gs, etc., can be placed on revers side). FOR DEPARTMENT USE ONLY I - DATE__, —— _APPLICATION ACCEPTED BY--------- v_ -,-2e BUILDING PERMIT ISSUED---------------- -- ----------I-------------------------- DATE C---------- ----- ---�,6- ---- - --------------- REVIEWED BY -I ------ --- DATE------------------------------------------------------------ Alterations and/or recommendations------------------------------------------------ -------------------------------------- - ----------------------------------- 11----------------- ---------------------------------------- ------------------------- ------------------------------------------------------------------------------------------------------I----------------------------------- ---------- ------------------------------------------------------------ -------------------------------------------------------------------------------------------------------------------- -------------------------------------- ---------------------------------1-1---- ----- ---------------------- ------------------- --------------------------------------------------------------------- ----------------------------------------- ---------------- ---------------- -------- ---------------- -- ----------------------------------------------------------------- - --------- ------------------------------ ----------- -D 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 10-52 Revised W-2100