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N'3 3f � APPLICATION FOR SANITATION PERMIT Permit No- (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to and install the work herein described. This application is made in compliance with County Ordinance No. 549, c JOB ADDRESS AND LOCATlON !- --aS'V p - Owner's Name_---------- {�l_ 1 ` --------------------------------------------------- Phone__ Address -----------/0-2— Contractor's 0. N �Q --------•--•---------------------------------------------------- Contractor`s Name___ L>✓�i,a.grj�; �+.i,.c�, ------ ----------- Phone- ------ Installation will serve: Residence [g Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._ Number of bedrooms -1---- Number of baths Lot size -XO Water Supply: Public system ❑ -a- y s system ❑ Depth to Water Table ----- ft, Character of soil to a depth of 3 feet: Sand p Gravel ❑ Sandy Loam Clay Loam [] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 0 New Construction: Yes;K No ❑ 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_S- �.___Distanc from foundation...... -p ----.Ma#anal------ -�'-- •C� ------------ No. I71 of com artments____ - _Size q p p - --7- --------Liquid del?* -------------Capacity-- �`f¢ foundation 6crz i' Disposal Field: Distance from nearestell ----__pistance from foundation_ _�s�___-____.Distance to nearest lot line____ _____7 Number of lines-----------ZLength of each line------e_.a-7"---------Widthof trench-o�_�ss -- Type of filter material-_ / - �t ! °�--- ___Depth of filter material_-_. _.___.___Total length_____4�Q Seepage Pit: Distance to nearest well----------------------Distance from foundation-------------------Distance to nearest 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------------------------------------------ ❑ Distance to nearest lot line_________ _________ _________ Remodeling and/or repairing (describe);----*_-_ ,$l _ �F - ---•------------- 1 ------•-----•--------------••----------------------- •-----------------•---------------------•---------------------•--------------------- ----------- -------------------------------------- W ------------ -----------------------------------------------------------------------•------• -----------------------•---------------•-----------------------------------------------------------•----------- I hereby certify that I hav repared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and ru s nd regulati sof the San Joaquin Local Health District. (Signed) -- ---- - Contractor By:------------ ---------------------••---------------------- - -------(Title)-- ----------- -- (Plot plan, showing size of lot, location of system in rela i to wells, buil mgs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY�--------------------- ------------------------------ ---------------•--------- ------ DATE_ ---------------- REVIEWED BUILDING PERMITU ------------- ---------------------------------------------------------- --- ----------------------------------------- ------------------------------------------ DATE---y-------------------------------------------------- ------- DATE-- _ ", Alterations and/or recommendations:------- _________ #s ------------------------- _ -------- -------------------------------------------------------------------------------- F ------------------------------------- -)- - ------- --------- FINAL INSPECTION BY_________ i 1 r 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 ES-9-2M 10-52 Revised W-2100