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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / Date Issued --- / Applica�ion is hereby made to tits San Joaquin Local Heal#h District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549, JOB ADDRESS AN DO�CATIONy �' ` -f: -------- ------- ----------------------------- A� Owner's Name_- _ s � Sp - ._. one-----�--------------•------•----•--- Address Contractor's Name _ ------------------------------------------------- -------------•- : � .1_i•_L7� .- 1_' `----------------------------------- , ----------• ------------•�----------•----- Phone% Cry-_��--�---- Installation will serve:."..Residence ��a�tment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of_bedroo s _- umber of baths ---4-- Lot size ----------------- Water Supply: Pul;lic system C ni+y' system ❑ i` Private F "P...... ❑ depth to Water Table --,__--- ft. Character of soil to a depth of 3 feet: Sand ❑. Gravel ❑. Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W_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-) U'm __Septic Tank: Distance from nearest weldG4!% Distance from foundation_ 1 -- aterial-- _---- hjC �. - -z ®� No. of compartments-----_ - -----------Size"1_ ---if- '7, Liqu' _epth__ -��__ .Capacity ��-� Disposal Field: Distance from nearest well-. 11,�'+Mistance from foundation__?_P__/_.D'istance to nearest lot line-----n__f_ W� Number of lines---.___-_--_.- Yp `---_ Len th of each line------ -5'_�--- Width of trench----e --CSC-`!________________ T e of fitter materral-_--1--�� -^Dep h of filter mai y .. anal------f-�F�--,Total- length------�-� eepage Pit: Distance to nearest w a I 131 AVZ_Distance f om foundation_-- _Distance to nearest lot line--;F�_�/-_ Number of pits-------J.----------Lining material-- �¢'l_�C e�-Size: Diameter--- 3------------Depth------ - --f----- Cesspool: Distance from nearest well---------------:Distance from foundation--.._------- ---_.Lining material------- ------------------------- _ ❑ Size: Diameter------------------ ----Depth-------------------- ----- --- - -----------Liquid Capacity----------------------------gals. Privy:t` Distance from nearest well- --__--------------------- ---Distance from nearest building---' -. -r ------ ------------------- ❑ Distance to nearest lot line----------------`"'.-_--:--_-.- - � � - �- _. -------------------- ------------------------------------------------•-----------•-------------------- =' ------- ---------------- and/or repairing (describe]:_- /`,/`G-------- L1 �?`,�ff = Xf - ••--- -------------•--- ••------------ -- -•-----------•-------------------- ------------------------------------•------------------••-----------•--------------------------------•------------------------------------------------------- -------•---- ---------•----------------------------------- I here6y certify that I have prepared this application and that fhe 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)--- ---�-.�/+�----------------•------. IA16. - a - U7__ r and/or Contractor). Title l {Piot plan, s owing:size of lot, location of system in relation to wells, buildings,.etc., can be placed an reverse side). t FOR'DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- R EV f EW ED BY ` - -----•-------- DATE- ---------• ----------------------- ----------------- =--------=-�----------= - --- BUILDING PERMIT ISS-UE D _ ----------------------------------- -------------------------•---- DATE_-�---------------------- ----- --------------------------------------------0-- --- DATE------ , Alterations and/or recommendations:___.�-----------------=- -- ;C ^-------------------------------------- -------------- •------------`----------------` -,-^---_b•------- -----------------------•------•- w ------------------- ----------------------------------- ----------------------------------------------•---------s-'-•------------------------ F1NAL-INSPECTION a13Y: -, ".` Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street '30D West Oak Street 132 Sycamore Street 84 North "C" Street r Stockton,'Celifornia L,odi, California Manteca, California Tracy, California ES-9-2M Revised W-2100