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APPLICATION FOR SANITATION PERMIT Permit No. .4-70--- (Complete - ____1.____0__I(Complete in Duplicate) IN4Date Issued I-��I�rr_ra 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. ST JOB ADDRESS AND LOCATION o`` Atep Owner's Name ------ ------- /+---- 1------ -------------------7 Address. I __ �-- ------ J Contractor's Name--------•-----------------• - ---- -- ---------------------•------------ - --------------------------•------ ----- •-------- Phone----------------------------------- Installation will serve: Residencek Apart nt. House ❑ Commercial ❑ Trailer Court ❑ Motel '❑ Other ❑ Number of living units: 1-. Number of bedrooms 4---- Number of baths ___I___ Lot size _, -_.�5.. = ___________________ Water Supply: Public system ❑ Community system ❑ Private k, Depth to Water Table - ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam'❑ Clay Loam ❑ Clay [] Adob Hardpan ❑ Previous Application Made: Yes n Nog New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank"or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: e from nearest wel �. 'Qistance from foundation____ _____.MateriaL_____ �•:_ ____ ._. k No. f compartments-------------------- ------Size--------------------------------Liquid depth---------- ---------------Capacity---------------------- M D;s3 I Fi Id: Dista ce from nearest well Distance from foundatio _� Distance to nearest lot line_�_..� 4 °I—ff � _ Number o.1 lines_________ ______ ___ _________Length of each line_______b-._ _!� .Width of trent . - 0P--.______..________: Type of filter materia�___ epth of filter material___.__ ___ _. Total length__ r 6-------- --------------------------------- Seepage Pit: Distance to nearest woIl--- -------------------Distance from foundation--------------------Distance to nearest lot line__._______-____._ _�11 ❑ Number of pits--------------"-'"-Lining material----------------------.Size: Diameter-----------------------Depth------------------------_-..� x. Cesspool: Distance from nearest well"%_-___+____.-_Distance from foundation_____ ___________Lining material-------------------------------------- Y) ❑ Size: Diameter-------------Y�------------------------Depth--------------------------------------------------:-Liquid Capacity------------------- --------gals. ; Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---.------------------------------......... ❑ Distance to nearest lot G ----------------------------------------------------------------------------------------------- ------- --- ------------------ iltRemodeling n or epairing (describe):______.. _.._-------•- � -- ______ __ �- --••------ --- -----•--- -------- ---• = �: ---- ----------- -------------------------------- - C ------------------------------------------y ---------------.------ --------__ _______ _____-___ w - ---� - - '�6 - ------- ---- - � � �''` = I hereby certify that I h�prepared this application and that the work will be done in accordance with San Joaquin County ordinances,,-5')8te laws, d rules�a, regulations of th��n�Joaquin_ .Local�ylth Di #„ � ��Sr� (Signed)- ----- By: 0►Y•rh+ 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). r FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY------------------ - -- -- ---- ------------------------------_-------•--r,-_—.-__ DATE--------------• ------------•------------------------------- REVIEWED BY------------------------------------------ - -- ---. DATE----- - --- ---------------------------------------- BUILDING PERMIT ISSUED------------- -------------------------------------- - ------------------------------------- DATE------ ------------------------------' - Alterations and/or recommendations-----------------------------------------------------------------------------------------------•--•-------------------------- ---------------------------- ------------------------------- --------------------•------------------------ ---------------------- ----------------------------------------•----•-•-----------------------.•------------------------------------------------ -•---- -------------------------------------------------------------------------------------------------------------------------------------------- ----------- --------------------•-------------------------------- �ti ---------------------------------- --------------- ----•--� --- --------- -------- ------------------------------------ W FINAL INSPECTION BY:. [date --------------- �7i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Stree+ Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100