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b ✓./� . C;, � 1711 -.16�' I APPLICATION FOR SANITATION PERMIT Pe—it Nn. ._'12 / S.�____ ` (Complete in Duplicate) a e Issued _J Application 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 LO AT10N : --------------- -ftp " ,, ` -- 1'`� �p__ - Ys �� � - h�• ,51-Y - f---------------- Phone --/yX----------------------- Owner's Name --1------ Address--------------- �T+ /►f, De /`� p��:j�_l��",�� WY-161.r��r�/ � / Contractor's Name--�-d-----fi-tv---------=1 - -I C TT------- Q �F�' r Phone_--=._�/��7_---- 1 1--- ! Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: L1.9,Number of bedroomsQ�2LNumber of baths Lot size :;�74___,�_____1_,1.�_____________________ Water Supply: Public system ❑ Community system fl Private ❑ Depth to Waterjable.�_ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No Pk New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: r (No septic tank or cesspool permitted if public sewer is available within 240 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material_______________---__.-___-______________________.- ❑ No. of compartments--------------------------Size----------------- -------------Liquid depth--------------------------Capacity....----os `-------- r Dis € Field: Distance from nearest well__-- -�_r__Distance from foundation__ _" ___`____.Distance to nearest totline.��.._... �� Number of lines----ffMS__Tr Length of each line__. ____ __ Width of trench_*"___--_--_----______ Type of filter materia€._'��---R9_M_.Depth of filter mater -1_---------Total length-------- ______________________ J Seepage Pit: Distance to nearest well----------------------Distance from foundation---.--------.-------Distance to,mearest lot line------___-_______ ❑ 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 `Ch ❑ Distance to nearest lot line---------------------------------------------------------------------.----•-•- ------------------ --------------------------------- - ---- 1 1 Remodeling and/or repairing (describe):___. _ ----------------------------------------- -- ---Y ------, ►� ____ ' ___ �� ------------------------------------------------------------------------_A�M �0A1 -- � � -- hereby }i +hat I have prepared this a plication and that the work will 6e done in accordance with San Joaquin County # ordinances, State aws, a d rul s and r ion of the San Joaquin�Local Health District. (Signed --• ---- - a 7 I �� 4---- ----- Owner and/or Contractor / - ( / ) BY� GL-� - ------------- ------ (Title) r _� �� (Plot plan, showing size of lot,-location of system in rel& ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY .r APPLICATION ACCEPTED BY---- ----- ------------------- DATE--- --------------------------------------- REVIEWED BY---- ------------------------------------------- DATE r BUILDING PERMIT ISSUED DATE--- Alterationsand/or recommendations----------------------------------- ---------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------L--------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------•--------•---------------------------------------------------- --------------------------------- 4----- ------------------------------------ ------- -------------------------------------------- ---------------------------------------- -------------•------------- ------ ----------------------------------------------------- FINAL INSPECTION BY:------ .- - --------------------- Date-----_--�_t!_ __ _._ 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 E5-9---2M 9-51 Revised W-2100