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it APPLICATION FOR SANITATION PERMIT Permit No. ., -_d__.___.. (Complete in Duplicate) �I Date Issued IR Applica+ion 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 Ordinance Nal. 549. I` , JOB ADDRESS AND LOCATION.----- -- .. �' ' '- Owner's Name--------- a ------ ---? ---- 1 ----- ---- -j�----------------------------------------- Phone------------------------------------ 1-1 -__: '4 �" Address._._. 'M - ---------- ---- --------- -- - - ---- ------ ---- Contractor's Name--- ----- p &Z-`-- - Afif- _.-"�------ --- ----------•------------------- Phone �'� 3 Installation will serve: Residence Apartment House ❑ Commercial '❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -- Number of bedrooms _. Number of b the 4--- Lot size ____--�� - ---- d- --------------------- :i�: '� Water Supply: Public system 'C] "Community system ❑ Private Depth to Water Table, 4r ft. Character of soil to a depth 'of 3 feet: Send ❑�Gravel ❑ Sandy Loam ❑okay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes u IJo ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- Disfanceih No, of compartments 2from nearest wedll_� Distance from fo ation___P --------Mat rial___(7__ ___ ____________ _____-_-__ __ tri .: __-Size.___v�'' rs.,c{. d d _ .Liquiepth _ ___ ------Capacity---- �f __ ___. Disposal Fief Distance from nearest well d._:_._.-Distance from foundation__ _ Distance to nearest lot.kin._�o------ P �,� p10, Number. of lines___-_!d�^'�/- �+ Length of each line_____._ "� Width of trench___.______ T e of filter material. ,_ _._�__- Depth of filter material____.__ `--____.____Total length_______ _• _______________________ YP ��. �,, ff _ / f Seepage Pit: Distance to nearest,well.I_70--------Distance from fo ndation_/X4--_____.D•stance to nearest lot line__l�/._--_____ [ � Number'tlof pits__,eQv _-_-.---Lining material—AC Diameter` ------------Depth_____, �_ � 1 Cesspool: Distance" from nearest well___._______.____Distance from foundation--------------------Lining material--.---------------------------------- Size: Diameter--!7"r7"----------- - t ❑ Depth---------------------_-----------------------------Liquid Capacity----------------------------gals. Privy: Distance from rom nearest well ________________-------------------_____________Distance from nearest building------___-___________________-__________. ❑ Distance to nearest lot II k line---------------! ----------------------------------------=--------•-------------------------------------•----------- Remodeling and/or ____. __ --____ __--. . 1� ' -- - ------------ -•---•-�''-- - -- - -- -- __ 4 ---------------------------- ------------ ----------- ------- _ l - -- .. a�- ---• - - ----•------------------- 5�. _.. = ---------- - • -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Safi Joaquin County ordinances, State la_w... �nd(,rules and,re.,gulations of the San oaquin Local Health Dis �ict. (Signed) LOwn a , oContractor) 40-- .. ----------. __ ' ----------------------------------------=--------------------(Title) ------------------------------ ----------------B (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). _ f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDI'BY------------------------------------------ ----- L - ---j�- DATE-•---------- � —�C REVIEWED BY /�j DATE. -------------��-------------- ------- ----- -------------------------- ------- --- ------------------------------- ----------------------------- BUILDINGPERMIT ISSUE6---------------------------------- ---------------------------------------------------------------- DATE------------------------------------------------------------ Alterationsand/or recommendations-------------------------------------------------------------------•--------------•------------•-•----------------------------------------•------.--_--------- il •----------------------•--------------•--------------------------------------------------•---------- -----------------•----------•----------- ------------------------------------------.----------------- ----------- il I FINAL INSPECTION BYi- ------ Date-------- � - --�' -SAN JOAQUIN LOCAL HEALTH DISTRICT 11 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California II Lodi, California Manteca, California Tracy, California 111 ES-9-2M ; Revised W-21100