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l/ APPLICATION FOR SANITATION PERMIT Permit No. '- �t (Complete in Duplicate) / c, Date Issued Application 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 No. 549.. JOB ADDRESS AND LOCATION---------- .__ _ ___-_ Q f &7- Owner's Name------- -- W4�- CJts ------------------- Phone--- ..�-,� ,a-/ Address ----------------------•-.-.-----------------------•-----••-----�--- -- Contractor's Name t" a ------'------ e"it Phone -------------------- Installation o` '"±Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: .___ Number of bedrooms _ Number of b the __J__ Lot size ........._ ,5_�C-�„__ 7_____________________ Water Supply: Public system E] Commun:ity system E] ate PrivDepth to Water Table $J- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam F1 Clay ❑ Adobe 2-11ardpan ❑ Previous Application Made: Yes ❑ No ew Construction: Yes ❑ No HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public swer is available within 200 feet.) Septic Ta Distance from nearest well---j7S--____Distance from foundation__-f-Q_---_ -Maternal-----G_�--1s!-l_C,_IC_'__ No. of compartments-._.__-,2---------------Size_____C�sX_y-6----:---Liquid depth-------i%.�------.Capacity...�o , Disposal Field: Distance.from nearest well__,V_4__/__Distance from foundation__�4__�-------Distance to nearest lot line----S......... Number of<lines---------/------------------------Length of each line--------9.##----_ �-____--.Width of french------ Y Type of filter --- -------Depth of filter material----- $_____________Total length--------__�0__--_-_______________ Seepage P' Distance to'nearest well-- 100- -------Distance from foundation____�Qlt_._:-Distance to nearest lot line_��_t__._ Number of pits______.I--------------Lining material_ eco----------Size: Diameter---Z—ee__...__ - p Cesspool: Distance from nearest well _______________Distance from foundation--------------------Lining material------------------------------------- 4 I ❑ Size: Diameter------------------------- ------Depth---- ----------------------- -------------------Liquid Capacity----------------------------gals. �n Privy: Distance from nearest well______________.______---------------------------Distance from nearest building----------.____.___________________._. ❑ Distance to nearest lot line----------------------------------------------------------------------------- --------------------------------------------------------------- Remodeling and repairing (describe):------------�=_ --- --------------------------•----------------,-----------•------------------------------------------------------------------------!:; ----------------------------------------------------------------------------------- �i� --------------------------------------------------------=------------------------------------------------------------------------------------•---- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County �I ordinances, State laws, and rules and regulations o the San Joaquin Local Health District. I (Signed) --- 6 --�'_ i g } �r Q�� (Owner and/or Contractor) By:- ------------------------•-----------------------------------------------------------------------------'------(Title) llL 14/-------------------------------- (Plot plan, showin size of lot, location of system in .relation to wells, buildings, of:, can be placed on reverse side). FOR DEPARTMENT USE ONLY +}f APPLICATION ACCEPTED 13Y DATE r A------------------------- REVIEWED ---- - i - -- ---------- REVIEWED BY-------------=------------------- - - ----------------- == _ - DATE-------- ------- I BUILDINGPERMIT ISSUED-------------------------- ------------------------------------------------------------------------ DATE------------------------------------------------------------ ;T Alterations and/or recommendations:-------------------------------------------•---------------------------------------------------------------------------•------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------------------- --------------•---•-------------------------------------_.------------------- --------------- ----------------- •--------- --------- ---------------------------- - --- ------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- -----------------------------------------------------------;----,�;------------------------------------------------------------------------------------- FINAL INSPECTION BY: ----=------- - ----------- Date------------------ -/------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revisea 1-57 F.P.CO.