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APPLICATION FOR SANITATION PERMIT Permit No. .�_4G._�__ (Complete in Duplicate) y/�yn Jl �7 Date Issued _'"__-[_____ rr!' -r M- �T 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. I 7 5 JOB DDRE AND LOC, TION ------- - -1'3''x- "-- - ---- =d ------ ------------------ -------------------------- r Owner's Name------------------ --- ---A4�'------�A^' 11N Q,! t "�---------------------- Phone------- ------ ------ ------------- Address l 84, ---•-- /'4r!°rR�--------- •------------------------------ ---------------------------- Y Contractor's Name-------------------------------•------------------------------------------------------------------------------------------ Phone ----------------------------------- Installation will serve: Residence Apart @nt House ❑ Commercial ❑ Trailer Court ❑ Mofel ❑ Other ❑ Number of living units: Number of bedrooms _X__ Number of baths ---�___-_ Lot size ------ II�X___E_+__G= ��- ---------------- Water Supply: Public system E] Community system [-]Private e Depth to Water Table ---A' - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe I'vr, Hardpan ❑ Previous Application Made: Yes ❑ No+❑" New Construction: Yes No ❑ i 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 ----- !_i- --------- Mate ial------- 3 e� ---- No. of corn partments---------- �;s--------- Size ---- •- X-tft% ,---Liquid derr��pth--------- -----------Capacity---9-0-C---------- Disposal Field: Distance from nearest well--- -/ * 9- Distance from foundation________ -7 ------ to nearest lot line ___8--_________ Number of lines______________ ______________ __ Length of each line_______ D Width of trench----.-�Q____�tl+tir_A___ 1 g f ca - Type of filter material____S_ - _Depth of filter material ---- 100-'�--------- Total length ------ /�_o____________________ �. Seepage Pit: Distance to nearest weft ------------- _-------- 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 ------------------------------------- C Size: amefer-------------------------------------De th----------------------- _-- - - - ---------Li Liquid Capacity _ Di------------ ---- •-9als.� 1 Privy: Distance from nearest well-___----_--------- „--------------------- --Distance from nearest building ------------------------------ -----------. J ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------------------- ----. J Remodeling and/or repairing (describe):_. r___.___ + ---- = ---- ------------------------------------•-----------•-----•--•--- ------------------------- r--------------------------------------------------------------------•--•-----•----------------------------------------------------- --------------------------------------------------------------- ------------------------------------- ---------•---------•----------------------------------------------------------------------------------------------------- ------•--------------------•---------------------- ----- -- 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 i"u'les�and regulations of the San Joaquin Local Health District. (Signed}______;.9.__________/>?__f_______________. (Owner and/or Contractor) ------------------------------------------------------------------------ -- ----- By----------------------------------------------------------------------------------------------- ------------------------------------(Title)-------------------------------------------------------------- (Plot plan, showing size of lot. Iocation of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- --- '---- =_-- ---- - ------------------------------------- DATE-------------- --�-i.::.,,- - ------------•--------------- REVIEWED BY DATE ------11- -- ----- BUILDING PERMIT ISSUED ------------------------------ -- ------------------------------------------------------ DATE-------- --------------------------------------------------- Alterations and/or recommendations---------------- --------- ---------- ------- -------------------------------------------------•-----• :- FINAL INSPECTION BY---------------- ----- Date ------------ C" --5----------------------- 130 South American Street Stockton, California ES -9-2M 10-52 Revised W-2100 SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street Lodi, California Manteca, California Tracy, California