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APPLICATION FOR SANITATION PERMIT Permit No. __: ?__I..72—_ - (Complete in Duplicate) Data Issued Applic Thia{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described• s application is made in compliance with County Ordinance N,4.49. JOB ADDRESS AND LOCATION ---//91 YUp%lJ4 dS SGI! Owner's Name --------------- ------•�-ylNeli?_�___ :.-----•-- ------------------------- Phone----------------------- ------------------------------------ Address -------•----•---------------------------- ------------•------------- ---•- ----- •--------•--------------------------•---------•-------- -------------•-- Contractor's Name_ _________________ ----------- Phone ---------- Installation will serve: Residence �K ❑ Apartment House Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms --a.- Number of kA+hc l I .,+ t„e J/ Al-,,,, r_._- ------------ _____________ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table __4- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ff Hardpan ❑ Previous Application Made: Yes ❑ No lV New Construction: Yes No TYPE OF INSTALLATION AND SPECIFICATIONS: t (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Se ti Tank: Distance from nearest well �_ Distance from foundation_ ___ - - 149-- ------.Material --- ------------- No. of compartments_________________________Size____ rr �� -�(�--�--�----Liquid depth -------y�--------- - Capacity --- k�Q�/�'s-�' Dis sal Field: Distance from nearest well-___----tP.-..._ Distance from foundation___.___. __.Distance to nearest lot line _---__. _- Number of lines ----------- ro__---- 7.._J�-------- Length of each line__SP�i�c1Q% ,,Width of french.________ 2C'�__ Type or filter material----- _��--__________Depth of filter material________ ?y Total length ---------- % O -----_ -- ---------- Seepage Pit: Distance to nearest well ---------- _----------- Distance from foundation ------------ _------- Distance to nearest lot line El Number of pits------------------ --- Lining material -----------------------Size: Diameter----------------------- Depth --------------------------------- 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)__________________ ---------------------------------------------•-------------------------------------------- -•---•----------------------------------•----------•----------------------------------------•------------------------ 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 Jo uin Local Health District. (Signed)___.v ._ _____________________{Owner and/or Contractor) By: -------------------------------------------------------- Title ______ _____ (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 APPLICATION ACCEPTED BY ------------------ ---------------------------- -- -cr� DATE ------� - REVIEWEDBY ---------------------- --------------------- .......------------ -------------------- ------------•----------------- DATE------ -------•----- ----- ----- - ------------ BUILDING PERMIT ISSUED ---------------- -------------- DATE -------•---•---------- --------------- ----------------------- A aerations and/or recommendations________________ ----------- ---------------- - --------------------------- tt 7 FINAL INSPECTION BY:-_-_------------------------ - - -----1. ---•----------------- - Date --------I---- -----�---- -•- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street Stockton, California Lodi, California ES -9--2M Revised W-2100 132 Sycamore Street $14 North "C" Street Manteca, California Tracy, California