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r APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ .._.Date Issued ._7__ZP_.:�' Applica*ion is hereby made to the San Joaquin Local Health District for a permit to construct and a install the work herein described. -' This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_____________19 __t-_------•-__-• s Owner's Name-----------•-----•-•---------•--- -7JC2_�l 1x' �___-7---fJ- = ---------------------------- ---'------ Phone------------------------ Address------- ----------•-----------Address------- ------------ ------------•----•----- --------------------•------------------ Contracts-Name------=--------------------------------w' F_=---- ----- Phone-------•--- Installation will serve: Residence V Apartment°House❑ , Commercial ❑ Trailer Court ❑ Motel ❑ Other❑ 'Number of living units: ________ Number .--.?---f bedrooms ._ ___ Number of baths -9;--- Lot size ____:___ c /� z ----------------------------- Water Supply: Public system]. Community system ❑ Private ❑ Depth to Water Table -------- ft. Y Character of soil to a depth'of 3_feet:..'•Sand ❑ Gravel[ISandyrLoam E) Clay Loam E] Clay ❑ Adobe Hardpan E] Previous Application Made: Yes ❑ No ] New Construction:'.Yes No'❑k; '' '' ""_" � J ' TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) k� �. Septic Tank: Distance from nearest well_--.._f�'��-----Distance from foundation-----1_I)----------Material__-____- No; of compartments--.------X------------- ---------Liquid depth--------q4-:1 ---------capacity �13----j Disposal Field: +stance from nearest well------i10-..-Distance from foundation___-__-�"__---Distance to nearest lot line_:__$Z-.-�---_ ] umber of lines___________ __--_____Length of each line. _�-t7 " `n ✓ ` g ,- -----------�Q- -.Width of trench----------�'� V� Type or filter material______ Depth of filter material____ --------_--Total length_____________��Q I Seepage Pit: Distance to nearest well----------------------Distance from foundation_......._---_.__F___.Distance to nearest lot line------ ----------- t 1 Number of pits----------------------Lining 'material------------------------ Diameter-------------------------Depth---_-__---------------- + - Cesspool: ADistance from nearest well------------------Distance from foundation--------------------Lining material------------------------------------- ❑Rp Size: Diameter----- --------------------------------Depth------------------------------------------- --------Liquid Capacity----------------- gals. Privy: Distance from nearest well-----------------------------------------------__Distance from nearest building------------------------------------------- ❑ _ Distance to nearest lot line----------------------------------- Remodeling and/or,repairing (describe)-------------:-------------------------------------------------- --------------------------------- ------ ------------------•- ------- ----------------------- --- - - -----------_------------------------__-----------------------------------_ __________ ---___---------------------------------------------__------------------------------------------______________________________________ 'yam I hereby certify that I have prepared this app ication 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. (Signed) -_' --- - --------�----------------------------------------------------- `= :---.;-----:------- ----------------------- (Owner and/or Contractor)- - (Title) Plot Ian, showing size�f lot,aoc----- -- ------ - -----------'-------------------------------------------- --------- ----- ------ ---------- -- ----�--- - itle---------------.- ------------. ------------------------------ � . if ( p g anon of system in relation to wells buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------------------------------- ------11 -- DATE--------- - � ::� // ----- BUILDING PERMIT ISSUED f. REVIEWED,BY = DATE /J - / _i _6--------------------=--- --------------=-------•------ ----------------- DATE --------- -------------- Alterations and/or recommendations:-------------------------------- ------------------• i --- ------------•----------- ------------------------------------- _____________________________________________________ ____________________________________________________________________________ _. _________________________________ __________________________________ FINAL INSPECTION'-BY:-- ------"--=--- J}�l�}Z Pfij---------- ------------ Date.-------- .._1 =' - SAN JOAQUIN LOCAL HEALTH DISTRICT 4- 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California _ k E5=9--•2M ;. " Revised W-2100 y