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APPLICATION FOR SANITATION PERMIT Permit N_o --p.-v (Complete in Duplicate) ,..:.. Date Issued Application`is ereby made to the San'Joaquin Local Health District fo`r'-,a•.permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. r '� 1-s 7_ JOQ ADDRESS AND LOCATION-- -- : ;-____-- --------------------------- -------- --------------------------------------=------------------------------- -- - ---------- Owner's Name----- !/-- / --------- t---------- Phone_ " 4 G 2., �: Address.-----47..0..3_ ------------- '�� b --•---------- Contractor's Name_ Phone...------------------------- Installation will serve- Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ i Number of living units`: _ ._ Number of bedrooms __Z_ Number of baths ___�_ Lot size ----4_'s'__?_----I___8_4"---.----------------- . Water Supply: Public tem A"Community system ❑ Private ❑ Depth to Water Table ._Stift. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe PT r ardpan ❑ Previous Application Made: Yes ❑ No [ )New Construction: Yes 94--No E3 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.Q2.oz __Distance from foundation-----l ------ .Material__ --- ---_------------ ---- � �. No, of compartments____________ _. Size___.Y__,X__'7---A.57-Liquid depth-____-6�__�__._ Capacity--- -------Ca out �- --- Disposal Field: Distance from nearest Distance from foundation..._4�37"_-.-Distance to nearest lot line_____.__-__ --- Number of lines----------------7---------------Length of each line------------ Width of french_._.__.a_q_'1---------,------ Type of fi3ter material___PA.._ i______Depth of filter materlal------j.�_._---__Total length-------ts Q__ ____________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material-----------------------Size. Diameter------------------------Depth----------- ------------- ---___-. R Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---------------- - - ❑ Size: Diameter--------------------------------------Depth---------------------------------------------- ---Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------- -------._Distance'from nearest building._--_--._--_-__--_____________._.__..._. ❑ Distance to nearest lot line------------------------------ -----------------•------------------------------------------------------------------------ --- Remodeling and/or repairing (describe):-----------------------------------------------------------------------------------------------•----•--------------------------------------------------- 1 ---------------------------------------------------------------------- ----------------.-------------------------------------•- ---•--.._..----•---------- ------------------------------------------ ---------------- - ----------------------- ---------------- ----------------- ------------------ --------- ------------------------------------------- -------------------------------•----------------------- --- ----- 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 LDistrict. (Signed)__ r ----- ------- --------------------------------- � ef ee Contractor] G By:------- c} (Title)- j - "----- (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 .. . - - - REVIEWED BY DATE--__-Le ---------------------------------------------- 13lJILDING PERMIT ISStlED. - ------------------------------------------------------------------------------------ DATE------Ca---------------------------------- ---------------- 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 p _ ES-9-2M 10-52 Revised W-2100