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APPLICATION FOR SANITATION PERMIT Permit ..71-3 (Complete in Duplicate) Date Issued 477r ;Z_7* Applicalion is hereby made to the San Joaquin Local Health District for a permit to construct and install the workWi rein- 5 This application is made in compliance with County Ordinance No 549. ON ------------ ------- --- -- --- -- --- JOB ADDRESS AND LOC ------------- -v � .� -------------- Phone------ Owner's - -------T Owner's Nam ------------ ---- -- -----------------------------------------m--------------------•--•----------------• ---------- Address.-------41A - 4-----------0_3_�f------- ------------ Phone----------------------_---------- ----- - ----------- - - -------- Contractor's Name-------------- -------------- -- ---------- -------------------------------------- ---- r Installation will serve: Residencee arfmant House [I Commercial E] Trailer Court El Motel ❑ Other ❑ e' ----I_ Lot size ------L,?�A-) Number of living units: -- ---- Numb r of bedrooms -A Number of baths v .17 Community system E], -Private "Wa�f_er �upp' ly: 'Public system El . Depth to Water Sand ❑ Gravel F y L Clay El AdobeHar pan ❑ Character of soil to a depth of 3 feet: Sandy Loam E) Cla oam 0 Previous Application Made: Yes Ej No New Construction: Yes No El K TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cessp?ol, permitted if public sewer is available within, 200 feet.) ----------------------------------------- from foundation------------------Material------- Sep)ic-Tank: Distance from nearest well________________Distance No. of cornpartmen[s------ -----------------)Size---------- ----------------m---Liquid depth ------------- --------Capacity------------------------/ I"il d % -,/--- 11Z__ Disposal Field Distance from nearest weil_,$74,�___.Disfance from founclation-_ _0 0 1-- ---- . -_ . ...Distance to nearest I I Ine Nu�nber of lines--------- Z--------------------jength,of each Iine____.5040_`0��_.Widfh of trench------- -------- I Ty�e of filter material------- --------- --- ------------------- kepf� of filter material ----Total length------------1,0,0 Seepage Pit: Distance to nearest well----------------! __.Distance from-foundation.------------------Distance to nearest lot line_________________ m iameter-----------------r------Depth--------------------------------- El Number of pits----------------------Lining material------------------ ----Size: D nearest well----------------- foundation------------------- Lining material__.__.____-_.______-_._______--_____. Cesspo'ol: D�stahce.from n well_________.._---_Distance from Liquid_�ppacify_ Aals. Ell Size: Diameter--- 7--------- ---------.Depth----- ------------------------- ---------------Lic ------_----------- 's --—-------------------------------- -7bi ancerfrorn neares ru Privy:r Distance from nearest well-_ ---------- ------------------------------- E] Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------•------------i--------- ' -------------------------------------------------I--------- --------------------------------------------------- Remodeling and/or repairing (describe):- - .4--- -A - I I --------------- -------------------------------------------------------------------------------------- ----------------------------------- ---------------------------------------I------------------------------------------- ------------------------------------------------------------------------ ---------------- -------------------------------------------------- --------------------------------------------------------- ----------- k -------------------------------------------------------------------------------------------------- --------•-------------------------------------------------------------------------------------------------------------- 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. ) . P F ----------------(Owner and/or Contract (Signed)_+j.... 4 L-__-4-__?I AK ------------------- ---------------------------------------------------- (Title)------------------------------------------- ----------- ------ BY:----- (Plot plan. showing sizelocation of system in relation of lot. o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY DATE----------------------------------------- APPLIS7,ATION-ACCEPTED BY--- ----------------- -- --------------------------------------------------------- -_BY----E_ - -_ - - -- — ____h_ _ -1 e/ _77 "---'DATE-.:- REVIEWED --------------------------------- ------- ------ -- -- - -------------------- BUILDING PERMIT ISSUED--------------------------------- -------------------- DATE-------- ----------------------------- ---- BUILDING ------------------------------------------------------------------------------------- Alterations and/or recommendations:--------------- - ----------------------------•------------------------------------------------- I --------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- ------------------------------------------------------ ------------------------------------------------------------------------------------- ------------- - - -----------:---------------- --- ----------------------------- ----- ------------- --------------------- --- ----------- - - ---------------- ---------------------------------- - - - Date----- ----------------------------------- i --------------*------------------- FINAL INSPECTION-BY:---------- --- ------- -------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockfon, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100