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or APPLICATION FOR SANITATION PERMIT Permit No. �A-j-- (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. JOB ADDRESS AND LOCATION_ /�IJ� I_ -.�4- -IL4 IY��D� Ll: i Owner's Name - U. t r ` --- - ................... --=----- ------------------------- - Address _l7 " t ------------ ------•----------------------------------------------------------------------- ZI_11C�------------------------ Phone--- 7Contractor's Name_. CQ/ � - _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:(W_LNumber of bedrooms -Number of baths J__-_ Lot size -/_ __ ____ //'� ----___--_-_---_--__-_ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table ft. `�"+(V�; Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam ElClay Loam El Clay ElAdobeK Hardpan E] Previous Application Made:' Yes ❑ No D� New Construction: Yes ❑ No c 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--------------------Distance to nearest lot line--_-____-__---_-. ❑ Number of lines-------------------------- ------Length of each line------------------------------Width of french------------------------------------ Type of filter material-------------------------Depth of filter material-----------------------Total length----__-_--___-__-_-.___-___--_--_____---._ See a Pit: Distance to nearest welt- __-_ Distance om, fo ndation--- ____-_-.Distan�a to nearest lot Number ofpits__�'R�_---Lining material-- - -Size: Diameter__-_�- ------_ _Depth-- �lin-e--_-_---7------------------_- Cesspool , Distance from nearest well-----------------Distance from foundation--------------------Lining material------------------------------ ..._.-. - Size: Diameter------------------- - ----De th--------------------- ---------------------------Liquid Capacity ---------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----.--------------------._____----__-_-. "`' ,d. ❑ Distance to nearest lot line------------------------------------------------ --------------- Remodeling and/or repairing (describe):------- 4.71 --------------- -------t--•--------•- - tJ �n.....------ R.. ---------------------- -----------------------------••------------- ---•-------- --- --------------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------- I hereby cexxtify that I have prepared his application and that the work will be done in accordance with San Joaquin County ordinances, St ir, laws, and rules and re ulations of the San Joaqui ocal Health District. �� - -------==- / =-------------- (Signed) �= T == (Owner a dor Contractor) - _ // BY= ' rl�afion �a. -- Title--------- 1_. -------'--r -------------- (Plot'plan, showing size of lot, location of system in r to wells, buildings, etc., can be placed on reverse side). FOR D!~ ARTMENT USE ONLY APPLICATION ACCEPTED BY-- =3 f DATE--------- -----A-- ------- - REVIEWED BY - ------------------------------- DATE BUILDING PERMIT ISSUED-------------------------------------------------------- ---- --------------------------------------- DATE Alterations and/or recommendations:------------------------------------------------------------ ---------------------------------------------------•------------------------ ----------------------------------------------------------- ---------='------------------------------------------------------------- --------------------------------------- .- ------------------------------------------------------------------------- ---------------------------------- I e WV Z._.�- FINAL INSPECTION BY: �----------------------- Dade �` SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak S+reo+ 132 Sycamore Street 814 Nor+h "C" Street Stockton. California Lodi, California Manfeca, California Tracy, California FS-9-2ivl'S>SJ TRevised W-2100