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APPLICATION.-FOR, SANITATION PERMIT Permit No. 15.. (Complete in Duplicate) _ '-- Date IssuedX^_-2,Q_=-�9 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---- - �-- a 6-f------ Q' - ---- --------•---'-------------------------------------- IJ Owner s Name---Aa„i-1------{ 'a'• � -----•----- -----------------------------_ .-_-----m-. ;--�;--.:--; ----- -- Phone----------------------- - fJ ____________1------------------- ____________________________r____- ________-__- .___. _______t__.____.___.--._____._..__ Address-- -- Y..----�--- --r-•-•----•----------- Contractor's Name ----------- = Phone _a:.-f� - Q�2 s Installation will serve: Residence 10 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 4--- Number of bedroom's __2_ Number of baths -1.... Lot size _______________________ Water Supply: 'Public system Community system ❑ Private ❑ Depth to Water Table174 ft. Character of soil to a depth of 3 feet: Sand ❑ GrayTI ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ()( New Construction: Yes ❑ No 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--------------------Mat riaf________________----_-_----------_ ---_-_--___--- No' of compartments-------------------------Size-- It Liquid depth --------- Capacity_... Disposal Field: Distance from nearest well----------_-------Distance from foundation--------------------Distance to nearest lot line----------------- NUmb@f of,lines----------------------------------l Length of each line------------------------------Width'of trench----------------------------------- `De Depth of filter material__--_--_._-- Total length Type of filter material___-.______._____._ � p - ---- s g 1 � Seepage Pit: "Distance to neasest.well__QyI--^,L—_Distance fromfoundation: e.O-.�_'Distance to nearest lot line---- Number of pits-------_/-----------Lining material--- �i.`Size: Diameter.----, .�-_---_-__--Depth______Z:d--------------------- Cesspo_of Distance from nearest well---------------4i_Distance from.foundation_-:______-______-.Lining material-_--_.- ___-----..-__________-______. [] Size: Diameter ----------..Depth----------- Liquid Capacity gals. Privy:l Distance from nearest well-_____-______ ------------------------E_____-_Distance from nearest building__--________-_________________________- ❑ - Distance to nearest lot line----------- --------------------------------------------=-------=-----=-----------------==--------------- ------------------------------------ i Remodelingand/or repairing. (describe):-------------------------------------------------------------------------------------------------- ---•-----------------•-------------------------------- r ------------ ---------------- -----`- -- ------.T ------------------------------------------------------ •-------------------------------------•-------------------------•----------------------••------•----------------------------------------------•-•--•-------------------- 1 I hereby certify that I have prepared this application and than the work will`be done in accordance with San Joaquin County ordinances, State laws,`and rules and regulations of the San'Jcaquin Local Health Distr_id.' . r (Signed)...- (Owner and/or Contractor �� ------------------------------- By:--•--- ---------------------------------------------------------------------(Title)-- -- --------------------- (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 I APPLICATION ACCEPTED BY--------------------- ----------- DATE----------Q 1 IBY = •---------------------- DATE--------- -1- ---------------------------------------- REVIEWEDBU•ILDING PERMIT ISSUED.-----------------------------V----------------------------------.----------------------------•---- DATE------------------------------------------------------------- Alterationsand/or recammendations:-------------------------------------- --------------••-----------------------•-•-----------------•--•------- ----------------_••------•--•-----••----•------- --------------------- --------------------------------•---•-----------•-----------••---•-------------------------------•----•----------------------------------------------------- ----------------------------------------- ------------------------------------------------- ------------ ------- ------ --••-------------------•-------------• ----------------------------------------------------- ---------------------------------------r.. ------ ----------------------•-------------------- ------------------------------------------- ---------------------------------------•--------- - --------------------- o � 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 i �" S-9-2M Revised W-2100