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APPLICATION FOR SANITATION PERMIT permit No s.�.�Z (Complete-in Duplicafe) Applica+ion is hereby made'to the San Joe u' f " _ Date Issue 6 `,P This application is mad q in Local Health District for e �n compliance with County Ordinanc No. 549, a permit to construct and install the work herein described:.. i y - JOB ADDRESS AND CATION g�. !o ------------- ---------•-----Owner s Name - I `'J -----------------=•----- ----- Address. ,r=l of �.��_: "�. -----------•------- z.: „w -- � ---•----- ---- - Poe__ 't,� ------------------- ---- = _ .. Phone ontracfor s Name_______________ -•----- - ---• --- .- -- r ` -� - - -�-- ------ ��------------ ---------- --------------------l -- ----------------- Installation will serve: Residence ----- --------------------- ---- --- D�Apartment House Phone____" Commercial ❑ Trailer Court Number of livingunitsll _. ❑ Motel Other [] l_._ Number of bedrooms �-'^Number of baths __-�." -" Water Supply: Publics stem Lot,size ___ 4_ �Sr Y [��Community system -------- ❑ Private ❑ Depth�to�Water`7-able_�,�_- ft. Character of soil to a depfh of 3 feet: Sand iI r ❑ Gravel C] Sandy Loam Clay Loam ❑ Cl a ,�� Previous Application Made: Yes ❑ No Y ❑ Adobe 8 Hardpan ❑ ,,, Imo' , New Construction: Yes � No ❑j74" �'�`"' TYPE OF INSTALLATION AND SPECIFICATIONS: # (No septic tank or cesspool permitted if public sewer is available within 1fl0 feet.] S Rti Tank: Distance f om nearest well_______ t Distance from foundation_" ' - ' a No. of cornpartment�__ -- -------- Size------I - -.M terial----------------------•-----•------------------ .Field: isp Distance from nearest weft"_r._.--_ Liquid depth__----_-"------_------- -Capacity_.____- _-_Distance from foundation--------------------Distance to nearest lot line=______..__"" Number of' lines___________----------__ -----------Length of each line---------------------- t Width of trench------_-•-- Type of filter material________---_- --_ -Depth of filter material__________________ Seepa Pif: Distance to nearest wellz----Total length--------- ------------- �'J� ____Distance from foundation___ _ __:.Distance to nearest lot line r i Cess ool: Size: Diameter___r.� �umberofjpits-------- -------------Lining material_ 99 �� Depth----'2_.t"� p Distance fip�m nearest waif_____.______ _ 1 I --- Distance from.foundation_--___-"-""- ".Lining materia!__.___-"--._-""_" Size: Diamet`er - Depth's:--- Privy:: Distance frlolin nearest well------- -"- - Liquid. Capacity.-_-" ""-""______-___- gals. t :__ Dkistance from nearest building------------------------- ----------------------------------- -----"--"-- ❑ Distance to earest lot line_-"-'__- - M� _____________"""-_.- """"" ------------- -- '- ----- Remodeling and/or repairing (describe):----------- ------ yz ------------------- i ! - ; ------------------------------------------------------ _-__-__.-t______.._ • ------------------------------------------------------ _-__---_-_ _ ` _.__.------..--________________.__ i _-______-_________________________ _ ___-____._.__ _.__.__ J� -------- { - = I hereby certify that I have Iprepared this application and that the work will be done in accordance with San Joaquin County, ordinances laws, and rules a d regulations of the San Joaquin local Health District. � r I� (Signed)_. f + ..a, s•-•• �j?wn and/or Contractor)-------- •---- ----------{Title) - (Plot plan,.showing size of lot, to�ation of system in anon to wells, buildings, etc., can be placed reverse side). ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- REVIEWED -""-- ---" t"" - / REVIEWED BY = -- ----- -- ------ ---- - - =---•------•---- DATE----- _ . BUILDING PERMIT ISSUED-------------------- ---------- ------ ---------�---------------- DATE_ ----- - DATE_ Alterations and/or recommendations: __-"_.."_._ " - ----'------ --- " ---------------------- ----------------------- l ---------------------------------------------- - -----•------------ -------------------- -------------- ••---------- i -------------- _ - FINAL-INSPECTION -BY------------ <. tf✓''`� '7 .. -----------=----- ----- Date---------- -=- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street " Stockton, California 814 North "C' Street ' Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100