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�'X APPLICATION FOR SANITATION PERMIT Permit No. .1.� ------- (Complete in Duplicate) 3/ C� Date issued _.___---- — Applica+ion 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....-_ _ _____7 A `� .'._.�4__t/!'_P l�� _ -----------------------------..----------------------------------------- --------------- Owner's Name------G:.-_------��'3 S/�]/��a ��y .... Phone. ...... ?.�i�C1 U U Address--------- d d Y------A ----- ----------------------------------------•------------•-------------------------------------------•-------------•------------------- Contractor's Name----- -----•------------•~-----------��/ -'----------------- ----------- ------------------------------------ --------- 7 - !a g Iz i S H Installation will serve: Residence [F_Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel L❑ Other ❑ Number of living units: -------- Number of bedrooms _- ._ Number of baths -------- Lot size -----/ -___._______ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table_674� ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 2—Hardpan ❑ Previous Application Made: Yes ❑ No[�t'' 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: f Distance from nearest well ______________Distance from i ; foundation__._____:____.____.Material___________------ __-_ ____________._.____._. ❑ ( No. of compartments Size_____ Liquid depth__.__._____..___.___---__Ca acity----------------------- __________ ___ Disposal Field, Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line-___-_._.________ ❑ rk-ff�`"y Number olines Length of each line---------- -------------Width of trench.---- ------------------------ Ty7 tN , .?ate f Depth of filter material To#al length \` »� �[ Seepage Pit: Distance to nearest well-�.Q-0.�..___Dsstance from foundation___ --------Distance to nearest lot line_.:3�------- Number of pits---------/---------Lining material_0K1_YA�..Size: Diameter------0..........Dept h------- ________________ Cesspool: Distance from nearest well_________________Distance from foundation------------.------.Lining material--------------,_.._____________-___._ ❑ Size: Diameter--------------------------------------Depth---------------------------------- -----------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building__._____________________------------.-- ❑ Distance to nearest lot'line-------- ------ --------- --------- ----------------------------------------------------•-------------------------------------- Remodeling and/or repairing (describe):---�-UL__!r____/f_d_V!_0_L-----_1e11__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 the San Joaquin Local Health District. (Signed) � -.j..__. ner and/or Contractor By:---- -r -- --- = (Title) �- ------------------------------------------- (Plot plan, showing size of lot, ocation of system in relation to wells; buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------- - -----------�-,----------------------------------------------------- DATE------1�_ -----•------------------------------------------- �+ ---------------•--------------- REVIEWED BY-------------------------- ---- - -------------------- DATE---------- `----- ---- BUILDING PERMIT ISSUED -------------------------------------------------- DATE.. - -- Alterations and/or recommendations--------------- -- ---- -- -- -------____-------------------------------- --- --------------------- -------` - z --------------------------- ---------------------------------- -----------r--------- ---- ----- ------------- ---------•------- • - -------•-• ------ -- 4:: . --------------•-------------------- ---------...---------- ------------------•---` � ---- -------------------------�- ---- -----------�--------- --- ---------------- ---- .-----------------.---.---, FINAL INSPECTION BY:------'-------- r" ----------- 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 145446 ATWOOO 12-54