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77' APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) ' Date"Iss6dd Ap�liceion is hereby made to the San Joaquin Local Health District for a permit to cons;rijcf and install the work herein described. This application is made in compliance with County Ordinance N 49. JOB ADDRESS AN O�TJON Q e: _ - - ---------- ------------- Owner's Name ---------------- Address... ---------I.A----------i!!� Phone_¢_ S� •�' s.Q.r- Contractor's Name____ ;►_ � - -" ---•----- �---• ----------•-- •-- - -----•---•--- Phone_ ---�`�� U '�� Installation willserve: Residence [Apartment House ❑ Commercial ❑ Trailer CourtMotel ❑ Other ❑ ❑ Number of living units: __ f --__ Number of bedrooms _�:_ Number of baths -_�-- Lot size ----7Q__ __ Water Supply: Public system [L�Cornmunity system [] Private ❑- Depth to Water Table'�Q _� _,� _ft, Character of soil to a depth of 3 feet: - Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe grHerdpen ❑ Previous Application Made: Yes ❑ No 09/_New Construction: Yes ❑ No rC�r i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) epti Tank: Distance from nearest well------------------Distance from foundation__________ _ ____ _. ` ° -- - Material---------- ------- ------- -------- --=----------� No. of compartments_ Size--------------------------------Liquid depth--"--------------- Ca acit kP Y Disposal field; Distance from nearest well.�4�.�istance from foundation___-4.47 _----Distance to nearest lot line___-Z__--•,-_- �_ Number of lines-___--f---- -.-._ Length of each line____ ' * ii 9 v�.<ry- Width of trench a2"` Type of filter material_Sc ii - Depth o tenial-----/- -----_-- -Total length-_----�_D/ Seepage p'.t: Distance to nearest welld .� - ante o loon ati S-J Number of pits m _d___-•--.Distance to nearest lot hne----------------- -1-------------Lining aterial-- - ---- -- - -----Size Diameter---- �r Depth .' ------------------ Cesspool, V Distance from nearest wel!___-...____- -- e from anon.._.____.-__"__ Linin a g.material- - -_..Depth ,. ,.. Size: Diameter- ----- ---------- --- - ,.,�-�. -- - - ---------------------------Liquid Capacity-----------------------------gals.Privy: Distance from nearest well-.-------- _ ------------------- -Distance from nearest building = Distance to nearest lot line...--_._..__._.--_..____._ Remodeling and/or repairing (describe)_________________________ ---•-•----•---•------•--•-----•----------------•-----•--------•----:----------- -------•---•----••---•--• ---------------- •------------------------------------------------------- •------------------------------------------- --------------------------------------------------------------••-----------------•-----•----•---------••----•----•-----•-----------•---------------------------------- •------------- ------------------------------ -----------------------------------•-- -------------------------------------------- ------------------------------------------------------------------------ --------•-----•-----•-------------------------- ---- 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)--------- ---- _ ---- - --------------------------- _(Owner By:------- ------ and/or- ontract • C -- ------ (Title)- or) -----------------------------•--- -• ------- ------------- ------------------ ----- (Plot plan, showing size of lot, location of system in anon to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED 13Y ........ -- ---------------•---------•-------------- DATE-------BY --- ---- ..--- -- ------------------- ----------------------------- ---------- DATE-_- BUILDING PERMIT ISSUED__..-------- ------ - Alterations and/or recommendations:------- ----------------------------- DATE.------•----_-_-- __ -- -- ------ -------------------------------- -------------------- •--- ----- ............. - ---- ----------- f✓ - ._... -- ';�-�_ ---------- ------------------- -- --- - - -- ----- ---------------- ------------------------------------ - ------------------------------------------------------ ----------- ---------- ---------------------------- -------•----------------------------•----------- r FINAL INSPECTION BY:_..._--- - ------------ --------- - Date-- -1------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stock+on, Cel;fornia 814 North "C" Street Lodi, California Manteca, California Tracy, California ES-'� 145446 ATWOOO