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APPLICATION FOR SANITATION PERMIT ''rtPermit No. 4� __ _.__._:_ _ r (Complete in Duplicate) l� �afe Issued .�--. ------� ' O 3o-2.7 Ap licafion is hereby made to the San Joaquin Local Health District for a perrrsit to construct and install the work reinr�,cde�cribed. This application is made in compliance with County Ordinance No. 549. Ti �. "4,. JOB ADDRESS AND LOCATION ---------- a- 1. 719 Owner's Name------- -.---- ----------------------- ------------ - -------- - ----------------------------------- Phone -- •- --------- Address -------- Address.------=/--/-... ----- -------- ------�-----'Q-`�'�- --- ------ Contractor's Name------ ��-- f. .a - ��--�----------------------------------------- = P of n -- ;� - Installation will serve: Residence Apartment House ommercial ❑ Trailer Cour Motel ❑ Other-.per Number of living units:./_.-_._ Number of bedrooms Number of baths ___cP- Lo size ____ �_____ ____ __________ Wafer Supply: Public system Community system ❑ Private ❑ Depth to Water ble .3r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ C ay obe)' ,Hardpan ❑ Previous Application Made: Yes ❑ No x New Construction: Yes No E]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__ ____ _stance from foundation---A�--------- Material___.�________________-__-_________.le _____._. No. of eompartmenfs-.:-------�.-----.____Size__,r4_-XV.—AY-.f:___Liquid depth------ -�---_-Capacity-----A&A----- � ' Disposal Field: Distance from nearest well-________________Distance from foundation--- __d_ _____.Distance to nearest lot line______-r.�_ 4 Number of lines____ �_ __._____ __ Length of each line___.____- h_'____.`___._.t Width of tren ✓ --- --------------- l Type of filter material---- ___ ---Depth of filter material_______ _________Total length_--- �___ __ Seepage Pit: Distance to nearest well----------------------Distance from foundation---._P-*____._..Distance to nearer otSine__.�_- _ Number of pits-------/_--------- g �P-'-_ to ✓__Depth__._ D r ` --Linin material----=----- - �---Size: Diameter------ -- -- ---��----- -- --------------- 4 Cesspool: Distance from nearest well.__.--------------Distance from foundation_________________...Lining material____- _________.__.____- Size: Diameter-----------------------------------------Dept h-------- ---------------------- -----------------Liquid Capacity-----------------------------gals...- .-'- Privy: Distance from nearest well--------------------------------------------------Distance from nearest building-------------------------_____________-- f ❑ Distance to nearest lot line--------------- -------------------------------------------------------- Remodeling and/or rewiring (describe): ` ; , � r �- - - -- ------------------------- = , f -- -- --------- r ------------------•-----------------------------------------------------------------------------------------------,�'- ----------------------------------- I hereby certify that I have prepared this.application and that the-work will be done in accordance with San J ordinances, State laws, and rules and regulations of the San Joaquin Local Health Dist 1ct. Owner and or Contractor (Signed).. -------------------- By: - --------- ---- �� - --- -- - ----- ------------------------------------- ------------------ By:----------- ------ .._ �. r . -------------------------------------------------- [Tifie]- . -----------...... (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., an.be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- = ---------------- DATE- ' -- REVIEWED BY - `---- ----------------- - - DATE-- ATE f . .. � I ------------�- ----� -------------- �"..' DATE-•- ----------------------------------------- -------- BUILDING PERMIT ISSUED--------- 0 ------- Alterationsand/or recommendations:----------------------------- ------------------------------------------ -•--- ---------------------------------------- ----------- -----------•-------- -_--- • -------- ----- ------------------------ ------ ---------------------- --------- ----- ---- ------------------------------------------ -------------- ------------------------------------------------------ ------------------------------------------------ FINAL INSPECTION BY-------------- ----- -------------------- Date......5 1;�J- ----------------------- --------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton; California Lodi, California Manfeca, California Tracy, California e ES-9-2M I0-52 Revised W-2100