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1 APPLICATION FOR SANITATION PERMIT Permit No. -3-1-Y.0 �7• S 2— — f (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. 549. �� iC 7– t JOB ADDRESS AND LOCATION. _ Owner's Name . L / lUfi -------- Phone-, ` -- -_ ------------------ Address @1 /ti Y � ----------•------•--•--- Contractor's Name-------- ---------------_____ _dZ_( _�_SjE---- --_ Phone_.- p Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -Number of baths _"Lot size/49C-t_ Water Supply: Public system ❑ Community system ❑ Private A Depth to Water Table/0--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑- No New Construction:. Yes ❑ No K ' 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-----------------Distance from foundation--------------------Material _-__---____--- __-----__----____ - ------------ No. of compartments-------------------- Size--------------------------------Liquid depth--------------------------Capacity Disposal Field: Distance from nearest well_.--__._.Distance from foundation----_455Q_-_- -Distance to nearest-of lirt;-�fd._"_ - , - Number of lines-__�$Y .,. -[0.Length of each line--�6,0__ --------------Width of trench--- rf --------------i (`T? Type of filter material) f} i_eK,__Depth of filter material----/g_-_.......Total length-_/t4 -_____________________ Seepage Pit: Distance to nearest well'----------------------Distance from foundation--------------..__Distance to nearest lot line------------------- ' Pits -------Lining material-----------------------Size: Diameter------------------------ ❑ Number of its-----------•--- 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 buildingrte ` ---------------------------------------•- ❑ Distance to nearest lot line Remodeling and/or repairing (describe):--------_ - i ----------,_-_ _ _----__------- = ---------�a-------------- -----------.._ ..,, 9� Ael- -------•---- ----- ------------------------------------- ,� .. ��_+ _ -------------------------------------------------- -------------•---------------------------------------- I hereby cbrtify that I have prepared this applieafion and that the work will be done in accordance with San Joaquin County ordinances, State law , n rules and regulations ofSan Jo uin Local Health District. (Signed) :. `�f-- andl tractor) - -- �! -- Owner Con By--------------------- ----- -------- t ------------------(Titl(Ple) ----------- - - --- at plan, showing size o t, location of system in relation t wells, buildings, etc., can be placed n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- _ - -- - - - - - - - DATE REVIEWED BY------------------------------------------- -------------- DATE-_-_-_-_-_-_-_-_-_-_-_-_ _ - ,a-- ------------- _U;1 ---------- - - A10----------------------------------------- BUILDING - - ------------------------- PERMIT ISSUED--------------------------------------------------------------- --------- -------------.- - A terafions and/or recommendations:---------------------------------- ----------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------ ---------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------- ----------------- ----------------I--------------- --- ----------------------------------------------------------- -------------------------------------------------- ✓ ��FINAL INSPECTION BY----------------- ------ ---- --------- Date-----------�d 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 8-51 Revised W-2100