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z APPLICATION FOR SANITATION PERMIT Permit^No./ ______ (Complete in Duplicate) yy_S` Date Issued j- _ •---_____ 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 compliance,with-Goun# �iGrdinarsc Noy 549. �2_$ JOB ADDRESS AND LOCATION- ---- - _4e-r XA...... - Phr Phone------------------------------------ j Owners Name------------- _4,4-------l-t�4 FAddress.....•--•---------------- - �{--------------ft°.4rx��"`x�� --,/�-------F---------------------------------------------------------------------------- ----------------------- Contractor's Name----------- --•----------------------------------------------- -------------------------------------- Phone_--------------------------------- Installation will serve: Residence 1�4�partment House ❑ Commercial ❑ Trailer .Court ❑ Motel ❑ Other ❑ Number of living units: _J____ Number of bedrooms ___ Number of baths _I---__ Lot size _/tQ_- ___ ____________________________ Water Supply: Public system ❑ Community system ❑ Private ®---0epth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [�L-la_rdpan ❑ Previous Application Made: Yes ❑ No Construction: Yes [g—No ❑ 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_3�--Distance from foundation____9............ __.; No. of compartments P----------------Size3h-K__ _ _____Capacity p - - �i-�--�" -Liquid depth----��-- ---- •--�19rt2 - Disposal Field: Distance from nearest well___ t _-__-_Distance from foundation__ I�_-�-------Distance to nearest lot Iine.ZU_________- f r` Number of lines----------- -----------------------Length of each line------�m0____+i____-_---.Width of trench---� -_----------_-------.._ Type of filter material----1_}L_ZX.____Depth of filter material-----V15_______-____Total length________4_01__________________________ Seepage Pit: Distance to nearest well_____________________Distance from foundation-------------------Distance to nearest lot line_____---_--______ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth--------------------------------- Cesspool: Distance from nearest well_______________Distance from foundation---------------_____Lining material______.___________________--_____-. ❑ Size: Diameter------ --------------- ---------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privyi—°"'"—Dim-666- El --Distance❑ Distance to nearest lot fine------ ---------------------- ------------------•--------------------------------------------------------------- Remodeling and/or repairing (describe):-------------------------------------- ------------------------------------------------------------------------- --------------- -----------------------------------------------------------------------------•---------------------------------------------------------------------------------- ------------------------------------------------------------ +`- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (5igned)__,_/-�-i�- - -- -- _ l ------------------------------------------- ------------------------------------------- --(Owner and/or Contractor) r BY:-----------------------------------------------------------------------------------------------------------------------------------(Title)-------------------------- (Plot plan, showing size of lot, location of system in relation fo wells, buildings, etc., can be placed on reverse side). " FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------•--------- -----R_ 0-=------------- --------------------------------------- DATE-------i ----------------------------- ' REVIEWED BY---------------------------------------------------------------------------------------------------------- ----------------- DATE BUILDINGPERMIT ISSUED--------------------------------------------------------------- -------------------------------------- DATE------------------------------------------------------------- Alterations and/or recd mendations:------------------------------------------------- --------------------- ---------- ------------------------------------ .-.---•-------•----14-------- - - ` --f--�-.sI�'�' G . f. 1 y✓ -__ ____/ ---- __________ ______ _ __ _____________---------------_-----------------------------------------------------------------------� ------_ ___--_--------- r P ---' FINAL INSPECTION BY: Date - ------------------ ---------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 Wost Oak S+ree+ 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 8.51 Revised W-2100