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,4 �, � � APPLICATION FOR SANITATION PERMIT Permit No. (Complete im l)uplicafe) Date Issued A ' 1 5 1 Application is hereby made to the Sa oaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------ (- ----- Owners Name------------- -------------------------- --- Phone ---- +- Address ? / 2 " -------•-------------------------------------•------------- -----------------•--- ------- Address 4----------------••---- Contractor s Name---------------- ------------------------------- ----- ------------- one-------- --------- House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ �` Installation will serve: Residence p5 Apartment ❑ t dd Number of living units: __/__-- Number of bedrooms_'_ Number of baths!------- Lot size -Lt- - =---`--------------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. f soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam El Clay Loam ❑ Clay ❑ Adobe Hardpan E] t Character o r p � Pr vious Application Made: Yes 7No ❑ New Construction: Yes W.-Mb ❑ 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_ "_ --Distance from foundation--,-?- ____--i.Material-___ --&--L -------- ----------- No. of compartments Size` --------------------- ----------Liquid depth_.3--SNL --------CapacitY�'�t i<. Disp'osaI Field.: Distance from nearest well�C�[�-T---Distance from foundation----- --Distance to nearest lot line__��-__-.____ j r Number of lines--------- Length of each line- ,- 3..'4�_,_lt�-"C/Vicith of french ____ r • Type or filter material-------------------------Depth of filter material___r!_�------ ---- -.Total len th____- - ----------------- -------- from foundation--------------------Distance to nearest lot line_-_-------------- Seepage Pit: Distance to nearest well______________________Distance ❑ Number of pits----------------------Lining material------------------.- Size: Diameter----- El iameter---- - Depth Cesspool: Distance from nearest well_________________Distance from foundation----- material__-_.____________________._____.__.. ❑ Size: Diameter--------------------------------------Depth--------------------- -------- --------------------Liquid CapacitY- - ------------------------gals. . I m Privy: Distance from nearest well------------------------------------------------Distance from nearest building--------------------- --------- ---------- ❑ Distance to nearest lot line----------------------- --------------------------------------------- ------------------------------- ----------------- --------------------- Remodeling and/or 'repairing (describe):--------------------------------------------------------------------- ----`•----------------------- r --•---- ------- --------------•-------------------------------- _________ •------------------------------------------------------------------•-------------•--------------•--------------------------- I hereby certify'fhat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances. Stat laws, and rules and regulations of the San Joaquin Local Health District. i {Sign ------------------ ---- ------ ---- ----------------------------- ----- --------------•----- -----------------------------------------(Owner and/or Contractorl By:---__----------L__Y--..--------__ .___ . _____ ___ _ .-----.. . (Tifle}---------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY. DATE-------------------•------- - 2 K DATE---I""�__��-.I •�3-------- REVIEWED BY----------=---------------------------W_ _ - BUILDING PERMIT ISSUED---- ------- - ------------------------ DATE...-----•------ ... ;---------;--- Alte afions and or atom ndations: / �+ ` -------------- t`;_1 ".�._- ". :. "�` _ _ -'� tl ._.. -- '- �°___. ----------------------------- --------------------------------- ---------------------------- ------------------------------------ f� l I I r-zzr- Y _Am--- Date.......�-�---#---�----- - ----------------------------------- FINAL INSPECTION BY-------------- --------- - - SAN JOAQUIN LOCAL HEALTH DISTRICT Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street 132 S Y Stockton, California Lodi, California Manteca, California Tracy, California ,. E5-9--2M 10-52 Revised W-2100