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APPLICATION FOR SANITATION PERMIT Permit No.,�7_3__5 7 [Complete'in Dupl fief / 4, l ! Date Issued -__-__- Appliceion 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 o. 549., �y � ` I JOB ADDRESS AND LOCATION-..-__-_-64L 15_ Z F I ---------------------------•------ ------------------- - ----- -- --------- ----------------- ---------- JOB Name------------ = ► � A �� --- -----•---- -�ir�------------------------ •---------- ----------- -.- Phone Contractor's Name _-.._--_---•--------__-_ - •----- -- --•---- -------- Phone -t- ❑ 9 - Installation will server Residence A artment`House Commercial- - Trader Co urt ❑ Mote! ❑ Other ❑ Number of living units: -- - Number of bedrooms_. Number of baths - Lot:`size __-_-_-_- Water'Supply: Public system ommunit system y y ❑ Private ❑ Depthito Water Table -------- ft. Character of soll to depth of 3 feet: San�d�0_iL.Gravel•❑ Sandy LoamOil ❑ Clay Loa Clay Clay ❑ Adobe an r Previous Application Made: Yes ❑ No ew Construction: Yes o ❑ 4 P 0 TYPE OF INSTALLATION AND SPECIFICATIONS: ¢(No septic tank or cesspool permitted if public-ewer is available within 200 feet. / ' ' _ Septic Tank: Distance.from.nearest_well ----__ istanc fr fou ILr G-� Vepth-_.Materialo. of compartments--------------------------Size-_-• ---- q ----------Capacity-.-_ Disposal Field: Distance from nearest well'_ .D' rstance from foundatao ."_-__ _� ' 9 n � t+„r --- ,,Distance to nearest I�ine� Number of lines------------- ��--'` f Een t '� f.e'ch line----- •-1--- _-- --- _.Width of trench-.--- ------_-- Type,-ofefilter.material-�T-__Zk---D p �+ c e th,of,fiiter,.material---- --- -------}--_--tal 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------.--------I---Lining material'------------------------- ❑I Size: Diameter-------------------------------- ----Depth---- ------------------------------ Liquid CapacitY----------------------------gals. Privy: I Distance from nearest well___"----------------------------------------_-.-Distance from nearest❑ building----- ------------------------ p v --------.-. I"Distance to nearest lot line----------------------------------------------- -------------------- ------------ Remodeling and/or repairing (describe):___.--"" --------------------------- ----------------------••------------•---------•-•------ --•---------------------------------- -------------------••---------------•-------•-•------ --•--- Y y � prepared fihis a Ircafiion _ � � � _.,_W ordinances, State laws;and rules and regulations of the and that the work will be done in accordance with San Joaquin County ! hereby certify that I have San Joac{uin Local Health District. (Signed)----------•-•-- �. � ! --- --------- ------------- --------------------------"--------------- -----•----- ------(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 DWkRTMENTVSE ONLY APPLICATION ACCEPTED BY----.---------------------- --- ----------------------------------------- DATE.--- REVIEWED BYBUILI DING PERMIT ISSUED . ------------------------------------------ --------------------------- ----- - ----fierations .. DATE { ------------------------ -- ---------4-----_-------------'----------.. DATE-------1 and/or recommendations t ---•--- ---------------•-------- --•------------•---•---- --------- =-- ----- ----•---• - " ------------------------------------- - ---------------••--•-------•- ---------------------------------------------- -------------- ---------------------------------------- ------- -------•-"-•--•--------- FINAL INSPECTION BY:.-------- - _ _..- Date 7- - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D West Oak Street 132 Sycamore Street 814 North "C" Street k Stockton, California Lodi, California Manteca, California Tracy, California ` 2M Revised W-2100 S