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�i APPLICATION FOR SANITATION PERMIT Permit No�_P__._-_21___ j (Complete in Duplicate) �j Date Issued _______ Applica{ion 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. JOB ADDRESS AND S��`LOCATION.-----�- _ J -------&l -'-----4'�_ _P n--------------------------------------- ._---------._.._. Owner's Name----------l�V-t_- - }-°LyY1 - '------- a ".ley------------------------------------ ----- ---------•----- -- -- -- ------ Phone---------------------- - - - - - - Address1D `'--'� -• --------------------------------------------------------- Contractor's Name----------------------n-w.A_e.Y-------------------------------------------•----------------------------------------------- Phone.. U- Installation will serve: Residence'j Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -1------ Number of bedrooms ---- Number of baths I_____ Lot size ___ ---------------- Water Supply: Public system ❑ Community system ❑ Private 0 Depth to Water Table -------- ft. Character of soil to a depth -of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan ❑ Previous Application Made: Yes ❑ No ] New Construction: Yes 7Z No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: µ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) �1 Septic Tank: Distance from nearest well_-��"h_Distance, from foundation----f d_E ------.Materi�aL__�__�_�__�_wp_--`._.-__-__--. No. of compartments-----------..-i--------Size____-x�-----�`~-I,_--Liquid depth----------------------Capacity---- r r Disposal Field: Distance from nearwt well__J- Yo!&_Distance from foundation----10_Mly?__Distance to nearest lot Number of iines_____ _______________ Length of each I!ne_�Q�-74_��<<fP____.Width of french___-'�5_rfi___________---__.__-_ ' Type of.filter mafierial_S_T_, aG ___{Depth of filter material____.�1P_ _______Total length________-- 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 nea`resf'building------------------------------------------ ❑ Distance to nearest-lot line-----------------------------------------------------------------------------------------------------------------� Remodelingand/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------------------. ----------- ------------I.........----------------------------------------------------------------------------- -------•--------------•-------------------------•------------•-------•---------•-------------------------------- -••---•----...---•--••--------------------------••------------•------------=---------•--•-------------------------- -------------------------------------------------------I---------------------------------------------------------------------------------------------------------------------------------------------------------------------3 __ _ __ __ _ _ _ ___ ___ _ _ ____-_-.-___._..._-_________-_---_-_-_.____-_____________-_____________________ _-___-______________--____-_-_---__-___-__--__-__--___._-_- 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 7egml4ari of the San Joaquin Local Health District. Si ned --_Owner and,or--vnfra�ctor--------- ------------------------------------------------------------ ( f. .. By=----------------------------------••----•--------------------------------------------------------•-----•----------------------------(Title)------------•------------------------------------------------- - " .(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ham; '=--------------------- DATE / Z� C___---------.. .----------- REVIEWED BY ------. --------------------- DATE BUILDING PERMIT ISSUED-------------------------------------------------------------------•-------fifi•--- DATE --- Alterations and/or.recommendations:----------- ---- _ .------ ----- T --- ----------------------------------------------- ------- - ----------- ---------------------- -------w -------� -----U_�--- - ------•-------------------------------` � ---------------------------------------------------------------------------------------- ---------•---- - ------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------- --- -----•----------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY: = 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 ; Revised W-2100