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' tr APPLICATION FOR SANITATION PERMIT Permit lti. �3_ `-2 -- (Complete in Duplicate) Date Issued 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. 544. �`� f JOB ADDRESS AND LOCATION �,------1�/-r=--n--d5a-:-0,- , Owner's Name------------------- b-f /',Q------ � r_l _W e---�----------- --------------------------- Phone---- ----- Address---------------------------------A7-al ,------- Contractor's Name-------------------------------------------=----------------------------------- ------------------------------------------------------------ Phone—------------------------------- Installation will serve: Residence 0 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [❑ Other ❑ i �0- . Number of living units: I----- Number of bedrooms -_Irn- Number of baths --/--_ Lot size __- -__--- ,X-_�,,2 ----------------- Water Supply: Public system K Community system '❑ Private ❑ Depth to Water Table ----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe RJ 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.) Septic Tank: Distance from nearest well__�2Pa Distance from foundation--__- cz_- p /� Matial �_"h'lG'._ No. of compartments-------- -----------Size-f? f--1 _- -Liquid depth----- ---------------- Capacity-- t Disposal Field: Distance from nearest well-----" --------.Distance from foundation----_� __----Distance to nearest lot fine----3-:, Number of lines------------- .5- -------------------Length of each line----_-s�-'1��:d .Width oftrench------- ............. Type of filter material-------4_&fAd•Depth of filter materiaL___,/r-'!- --_Total length___--------1___.-,D--------------- -- o Seepage Pit. ` Distance to nearest well-------------------- -Distance from foundation--------------------Distance to nearest lot line---------_---__- Jam+ F1r Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth---------------------------------- Cesspool: Distance from nearest well_---------------Distance from foundation--------------------Lining material-------------------------------------- F] Size: Diameter--------------------------------------Depth------:---------------------------------------------Liquid Capacity----------------------------gals. R Privy: Distance from nearest well---------------------------------------------------Distance from nearest building------------------------------------------ El Distance to nearest lot line-- -------------------------------------------- Remodelingand/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)---- --------- � '�2'?' �"°� � ,"� (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 DSP RTME T USE Oa LY APPLICATION ACCEPTED 8Y. "" y*' r = '' DATE------ f -� REVIEWEDBY--------------------------------- ------------- - -------------------------------------------------------------- DATE------------ ----------------------------- BUILDING PERMIT ISSUED--------------------------------------------------------------•--------------------------------------- DATE Alterationsand/or recommendations-----------------------------------------------------------------------------------------------------•-------------------------------------------------•-------- ----------------------- --•-------------------------------------------------------------'---------------- -------- - -- ------- --- ------------------------------------------------------------------------------ -----------------------•---------------------------------------------------------------=-------------------- --- - - - ----- -----------•--------------------------------------------------------------------- ----------------------- ------------------------------------------ ---- - --------- FINAL INSPECTION BY:------------ ---- -- ------------- -----.- Date -------� - /7/�- -3 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100