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i APPLICATION FOR SANITATION PERM T Permit No (Complete in Duplicate) d!�`� aj 13671'. Date Issued App ication is hereby made to the San Joaquin Local Health District for a permit figco c ��5} Il the work herein described This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_________ �>a Owner's Name f--•--- L+ Sk - - ---- -- -- - -49� Address---- ---- � = G r�9 � - Phone. t-------------- LIZ- 4:f �Contractor's rfr r. Name nsta lation will serve: Residence ❑ Apartment House ❑ Commercial - --------------- Phone---- = 1 Number of livingunits: ❑ Trailer Court � Motel ❑ Other ❑ f�'�Number of bedrooms .------- Number of baths -------- Water Supply: Public s stem , � Lot size Y Community system Character of soil to a depth of 3 feet: Sand Y Y Gravel ❑Pr'Sand vate �oaDepth to Water Table .______- ft. ❑ Y ❑ ClayLoam Previous Application Made: Yes No ❑ New Construction: Yes ❑ No ❑ Cla ❑ Adabe❑ Hardpan ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: S�(No septic tank or cesspool permitted if public sewer is available within 200 feet.) ficTank: Distance from nearest well_______._.-__--_Distance from foundation________________,.y No. of.compartments----------- -------------------------------- --.Material -------------------------------- ---- Capacity ------ ----Size-------------------- -- -----Liquid depth- ----- ----........ �--- � D sal Field - -' - Numbee from nearest well------------------Distance from foundation________.-- Distance to nearest lotline______"_._____._. + Number of lines---------------------- ------------Length of each fine ------- -.- Type of filter material--------------- ----- --------- Width of trench---------- ------___Depth of filter material__-------__- -------•-- eS'e a ePit: _---------Total length--------------------------------- ---------------- r p g Distance to nearest welt-___-- pistance from foundation___.___-- _- ❑ Number of pits----------------------Lining material Distance to nearest lot line----------------- Cesspool: -----s-_--_ _ ! Cesspool: Distance fl-om nearest well_ Size: Diameter-------------- -- ----.Depth_ _-- -------------------------- El __ i ------------- istance from foundation------------Size: Diameter_________________ Lining material-__.__----- --- --- -- ----Depth--------------------------------- _ ----- ----------- ------ Privy: ' Liquid Capacity..---------- Distance from nearest wel!-------------- -gals. i t ______Distance from nearest building ❑ Distance to nearest lot line- ----_____-___--_--_ ---- ----------------- •--------------- Remodeling and/or repairing (describe]:_ e -------------------------------- -------------- ;-------------------------------- % - - ----- -- r_ ------------- n ��s --- --- -- --- - __a.�r�R.C_____ _._____ % - 4 I hereby certify that l have prepared this applicatio nd the a}~}h �r,ork will done in acro ante with San Joaquin ordinances, State laws, ------------ e regulations of the an Joaquin Local Health District, q County- (Signed)------- ounty(Signed)•------ ••------------ ::WA-4- ------- ---- "------------- ---------------------- BY= --••--•------• . •. • .-- ------------------ r Contract (Plof pian, showing size of lot, location of system in relation to wells, iid'mgs, etc., eran(bele)laced on o ) _ _ _ r --------------- P reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----"----.-._.-_ REVIEWED BY ----- ; DATE --- ------------------------------ ------ ------ ------------ ----- •- - BUILDING PERMIT ISSUED------------------- { -------------------------------------- - ATE------------- ----------- - --- •- --------- -- - Alterations and/or recommendations:---------------------�- - --- ------ ---------- ---------- DATE.._-----------------_---- - -- -------------------- E e T ----•-•---•--•----------- ^--- ----------- ----- ------------------------ FINAL INSPECTION BY:.... a }------ ----- Date--- _ --- i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California t E5-9-2M +0-52 Tracy, California I Revised W-2ioo