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ti ;t•� ,� Permit Na. �---�-v-�•----_�. 1.Y0 APPLICATION FOR SANITATION PERMIT ,( (Complete in Duplicate) Date Issued __-.---------��---•• A lila+ion is hereby made to the San Joaquin Local HealthdD'NoC 549r a permit to construct and install the work herein described. Ps This application is made 1n compliance with County ,�/ t -----•-----•-•--------------------------------- -----•- J` .' ------------ --------------- I----- JOB ADDRESS AND LOCATION-------. - Phone -- --------------------• ` "-x'0. 1..'----------------- --------------------------------- Owner's Name---- #r ----- --••-----••--•--- a ' Address------------ ----�_C;L Phone_- 9 P_7_ Contractor's Name------Aw. 1t W---Apartment House ❑ Commercial ❑ Trailer .Court ❑ Motel ❑ Other C]Installation will serve: .Residence Ap / tb--a------ --------------- Number of baths _- Lot size ___��'+ F Number-of living units: -------- Riumber of bedrooms -------- --De Depth }o Water -------- ff. Water Supply: Public system'[i�Community•system ❑ Private ❑ p Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan C] r Character of soil to a depth of 3 feet: Sand C1 Gravel ❑ any No [ � Previous Application Made: Yes ❑ No [.J ' New Construction: Yes ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tanNlo-t. cesspoolpermitted `sTe ----------------- p public sewer is available within 200 feet.) , ---Material------------------------------------------------- Septic ------- -- ----------•---- -----------Septic Tank: Distance from neareael ----.Distance from foundation----'---------= Liquid de th--------------------------Capacity----------------------- of ------------ ------ ofcompartments------------ -----------Size---------- ❑ �">r�5 y r pisposa] Field: Distance from nearest well ,. ---__.DLenath ofce reach-line----------------------------- om anon .--- --Width of}trenchQs�-lot line------- -- ---- Number of lines_----------- gTotal length ` Type or' filter material: :',Depth of filtermaterial--------------- --- - 9 �.� --Distanceo" T. �,� • s�/b -_Distance from foundation___I!�.--- ---� ista��e t nearest of ine _ Seepage Pit: to nearest well- YSize: Diame r_ 3 ------•-- -Deptn----_- ------ ©/" Number. of pits------�, Lining matenal_ L`i n material------- ----------------- ---------- _ t 9 Cesspool: Distance from:n wel --- ._--DiMance from foundation________ ________ _ --gals. De th ------------------------------ ----------Ligwd Capacity- -----------------------: ❑ Size: Diameter--------�--------- ---y�- p -----Distance from nearest building---------------------------------------- Privy: Distance from nearest well----------------------------------------------- ---------_---_._ -- ------------------------------ ❑ •� �- Distance'to nearest lot ine------ ----------- r 4 ____________________________Y____.__..___._________.__-____-________.____.__.______..______._______.__________. ______________ Remodeling and/or repairing (describe}------------------------------ -- _, ; ' Y - --------------- -•---•----------- ---•-------- = ------------------- - Y ----•------ --•----------i- ------- _ f ; - -------------- -- ----------------=------------- I hereby 11 certify that I have-.prepared this application and that the work will be one in accordance with San Joaquin County ordinances, Stat aws,` and rules and regulations of.the San Joaquin Local Healih District. ner and/or Contractor) �/�/�' �^ G --- --- ---------------- ----- d�° J ✓______ (Signed) --- �i E i --(Title) k By:.-- --------------------------- -� .w =--r- (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 ------ ---- ---------------------------- -- -- --------------•---•------ DATE _s-,,�" APPLICATION ACCEPTED BY---.--------------- ----- -- . DATE--------------- � ----------------•------------ --- ------------------ ------ --------- REVIEWED ------ - REVIEWEDBY----`------------------- ------------- DATE---------------------- BUILDING PERMIT ISSUED. -------------- - Alterations and/or recommendations:------- -- -------------------- ------ -------- -------- - ----------- ----- -------- ------- -- --- ----- r •--- ----------------- -- ----- -- ---- --- - --•- •- ----- FINAL INSPECTION BY-=------ - - - ----- - ---------------------- r _ Date__ SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 300 West Oal Street Tracy, California 130 South American Street Manteca, California Stockton, California Lodi, California 4 cc a—M.A Revised W-2100 - -