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2- APPLICATION FOR SANITATION PERMIT ermi o. . __ --l_ -__ Z (Complete in Duplicate) /- � p � Date Issued _�______1.....__. A�pliiccation 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 Ord nce No. 549, 4 J B ADDRESS AND LOCATION_ L �' QQ --- -- ----------------------- �,/------- Owner's Name---------------------,--•--------------------2_ --2-----9 9_a,----- � !!k'� �' Phone_ ------7_i�17�_ --------------------------------- _ -�---------- .--------- ------------- ~�'----------------------------------=----- Contractor's Name ---------- ---------- a A Pte- CY��£_�.k1tE=hone " �'f _ . �A Apartment House Commercial Trailer Court Motel Other ❑ Installation will serve: Residence� pa ❑ ❑ ❑ ❑ i Number of living units: Number of bedrooms _--KNumber of baths ___---__ Lot size _--- D 4 ------Z- ---a________________ Water Supply: Public sysi-emX Community system ❑ Private ❑ Depth to Wafer Table -------- ft. Character of soil to a depfih of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [8 Hardpan ❑ Previous Application Made:I Yes ❑ No , New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION7AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well----__-__j__---_Distance from foundation--------------------Material_--------._--------__------___________________-. ❑ No. of compartments--------------------------Size--------------------------------Liquiepth- Capacity of 11 Disposal Field: Distance from nearest well-_NX.�, _ - _Distance from foundation-_ -_-_________Disfance to nearest line._____.._._ Number of lines----------- Length of each line____��""�_Q'�---------Width of trench___________.'__-—--___----____ Type of filter material-- -t V__ _Depth of filter material......./__-'---__Total length______-_ Via_------------------- Seepage Pit: Distance fo nearest well----------------------Distance from foundation........-_.---------Distance to nearest lot line__-----_-------_ �(�+ ❑ Number of pits----------------------Lining material-----------------------Size- Diameter-----------------------Depth-------------:------------------- i Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-___-----__---_---_--____-_-____-.... Size: Diameter--------------------------------------De th-------------------..--._ --- ------Liquid Capacity gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building ❑ Distance to nearest lot line--------------- -------------------------------- ------------------------------------•----------------------------------------------•-------- i �,�p p Remod in and/or repair ng (descri e)________ ________ ___ __ �_ _ / ____ - __-__---------------------- f -•• 1t , -----------•-------------------------------------------------------------------------------------------------------•----------------------------------------------------------------------- .� I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State Iaw�� and rules-and regulations of fhe-Sa'n`-Jo"uin Local Health District. 1 � (Signed) '' 4 -- --- ------- -- ---------it' _-..q { ndl , Contractor) (Tifle) �t1[d- ----------- (Plot plan, showing size oflot, location of systein relation to wells, buildings, etc., can be pl ced on reverse side). l FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY y ---° ---------------------------------------------- --------------------=-- DAT --- ----- ---•----------------•------------------------- REVIEWEDBY------ - --------- --- ------ ---------------------------------------------------------------------- DATE--- BUILDINGPERMIT ISSUE.a------------------------------------------------------------------------------------------------------ DATE----- --------------- -------------------- Alterationsand/or recomMondations----------------------------------------------------------------------------------------------------------------------------•----------------------------------- --------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------:- ------------------------------------------------------------------------------------------------- ------------------------------------------------- ----------------------------------- FINAL INSPECTION B -------------- ---Y----------------- - ------------------------------------- Date-------------- - -- / - -_----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfre0 300 West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M B-5€ Revised W-2100 A