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pD r 7 APPLICATION FOR SANITATION PERMIT Permit No. _(Complete -- (Complete in Duplicate) Date Issued I Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 'E This application is made in compliance with County Ordinance No. 549. E d JOB ADDRESS AND LOCATION--------CA �!_6- k-I°-`-- Il f------------ T e-------- Owner's Name-----------a+. u-111------- '1 --------------------------------------" Ph ne f� Address 74W Cont ------------ ' :.. Contracfor's Name----------------- --------------------- - ----------------------------------------------------------------------------- Phone---------------------------------- Installation will serve: Residence �artment House ❑ Commercial ❑ Trailer Court ❑ Mote! LlOther E] Number of living.units: ___I__ Number of bedrooms __y Number baths ____/_ Lot size __� �'---� -• Water Supply: Public system ❑ Community system 'El Private De to Water Table J__U.ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam E] Clay E] Adobe E] Hardpan "" Previous Application Made: Yes El No [I!�New Construction: Yes [ No ❑ -TYPE OF INSTALLATION AND SPECIFICATIONS: _.,�(_.��... -� pool permitted if publics wer is available within 200 feet) 'x�.Y s - � �� .;�� Se tic �okse tic #aDkstance fr � 4i - ..w ' om nearest well____��_ __ istance from found n�__�f.�_____.Materiai ___ .��. - ----��----- ` p No. of compartments Size .�Ltquid depth Capacity-------- ------------- Disposal Field: Distance from nearest well__________________Distance tram foundation__--________________Distance to nearest lot line----------------- um er _______________umber of lines-----------------------------------Length of each line-----------------------------Width of trench------------------------------------ Type -------------:--------------------Type of filter material____________________ Depth of filter material-----------------------Total length----------------------------------------- Seepage Pit: Distance to nearest well___------94-------Distance from fo ndation-.-___IU-____-Distancsto nearest lof.lin e___ Number of pits---------,l__________Lining material__ Size: Diameter----2j6__11& _Depth_____ F Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________--________ ❑ Size: Diameter--------------------------------------Depth--------------.-------------------------------------Liquid Capacity----------------------------gals. Priv Distance from nearest well______ -------- ---- ------ 'Disfar�ce`from nearest`buil"dingy_ _______._ ______________.--__-_-__-. 4 ❑ Distance to nearest lot line----------------------------- ------------- ---------------------------------------------------=------------------------------------- - Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------I----------------------------- ------------------------------------------------------•-=------------------------------------------------------------------------------------- --------------------------- - -------------------------------------------e------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------ ------------------------------- - ---------------- ----------------=----------------------------------------••----------------------------------------------------------------------------------------------- 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 theSan Joaquin Local Health District. I Si ned ----- - ---------------------(Owner and/or Contractor) --------------------------- t F ---------------- ------ r [ --------- -------------- ------------ ----(Title)_ -- s.[Plot..plan-,.:showins4 size of-lot,:la�3#ion-c", systenv iwtresation1#o�+e��s;i,viiding3;'etc.; cen S' l ced or reverse side) '" FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ---- ----=--- - -- ------------- --------- DATE / 1✓ REVIEWEDBY----------------------------------- ------------------------------------------------------ ------------ DATE---------------------------------------------------------- ,. BUILDING PERMIT ISSUED--------------------------------------------------------------- ------ DATE---------------•---- - Alterationsand/or recommendations:--------------------------------------------------------------------------------------------------------------------------------------------------------------- -------------- -------------------------------------------------------------------------------------------------•---------------------------------------•-•-----------------------------------------------111-------------- ----------------------------------------------- -------------------------------------------- -------------------------- ----------------------------------------------------------------------------- ---------------•------------------------------------------------------ ------------------------------ ------- -------•---- -- ------------------- - --------------- •- - ------------------------------------------------------------------------------------ FINAL INSPECTION ---- ------ ---------------- Date---` ------- ---------------------- SAN JOAQUIN LO AL HEALTH DISTR 130 South American Street 4 300 West Oak Street 13Z Sycamore Street 814 North "C" Street Stockton, California � Lodi, CaliforniaManteca, California Tracy, California 1 ES-9-2M 8-51 Revised W-2100