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APPLICATION FOR SANITATION PERMIT Permit No. ! �. . (Complete in Duplicate) Date Issued 7._l-7S3 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. y JOB ADDRESS AND LOCATION------------------------- Owner's Name----------------------------- fL t�x`12 "V ' j't` /y+ /-V Z)A /C k S ---- Phone----------------------------------- ------- ti -----------------------------------�d ru ------------- Address------------------------------------------------------------------- ----------------------- --. Phone Contractor's Name-----------------•--------- Installation will serve: Residence [2. Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --1----- Number of bedrooms _-'YNumber of baths __/--- Lot size ----------- Q X--�-(° Q---------------------- t Water Supply: Public system 0 Community system ❑ Private ❑ k k Depth to Wafter Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Cli y ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS;,r�_ _.R_--- -• - -�- (No septic tank or cesspool permitted if public sewer is available within 200A)i Septic Tank: Distance from nearest well------- ---Distance from foundation-----_d---------.Matetia4._ .___------- ---------- --- --- No. of compartments--------•-�--- ----size----Z_'�9-�--�---------Liquid depth---- --4--- -----Capauty CJ i Dis os Field: sDistance from nearest well-.-�''�'__- Distance from foundation------1-0--------Distance to nearest lot line it_-------. Number of lines-- ------ ------- Length of each lin e-----------�n� --------Width of trench------------2------------------- t ----Total length------------------1 Z-a------- Type of filter matenal--�I----------- --Depth of filter material----._-��-__ Seepage Pit: Distanc AY.mearest well----------------------Distance from foundation-_-----__- -_.Distance to nearest lot line-__...- ---___ Numberof pits-_�+►_�:- } Lining-material- l Size: Diameter---------- --------Depth--------------------------------- ❑ Cesspool: Distance from nearest well---_--_----__.---Distance from foundation.-.------__-------.Lining material--.___-------------------------els. ❑ ----------Liquid Capacity--- •-----------------------g Size: Diamel•er------ --------��-------- ----Depth-------- ---------------------- ------ Distance from nearest veli--- ---------- Distance from nearest building------------- ------------------ ❑ -----•- ------------------------------------------------- LJ -- - Distance to nearest lot 1in�----------------------------------------------------------- 1--% Remodeling and/or repairing (describe):-------_-.-`----------------------- ---------------- ..................... -------------•----- ------------------------ ------------------- ---------------------------•-------- ----•-------------f------------------------------•--- - --`------= ------- ---------- ----•---------------------------------------- ----- - ------------------•-------------------- 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 afid regulations of the San Joaquin Local Health District. (Signed)_` _- ---------------Owner and/or Contractor) ��/ . ----------- --------- ----+ir -1-�------ �----- - - -�-�-• t-= - ---------- -- { .._.. --- ----;r By:--------------•--------------------- - ----- (Piot plan, showing size of lot, 1 cation of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT;USE ONLY 1 APPLICATION ACCEPTED BY�----------------------------------- ' DATE------------ -- / �-t y �j DATE------------------------------------------------------------ ------ -------- REVIEWED ATE-------------------•---------------------------------------- REVIEWED BY- } ------ ------- DATE------ ------------------------------------------------- BUILDING PERMIT ISSUED_>-------------------------- -------------------------- ---------------------- Alterations and/or recommendations:----------------------------------------------------- --------------- - .. ----------------•----------•------------------------------------------------- ----- •----•------ ----•-------•------- ------------------------------------------------------------- - �- ------ - ------ ^- -f/&}-----)V------ w r FIN It, ECTI BY---------------------- Date - --------- --------------- ------ - �` G+ SAN JOAQUIN LOCAL HEALTH DISTRICT 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street 130_ ouch American Street TracCalifornia Stockton, California Lodi, California Manteca, California y. ES--9-2M 10-52 Revised W-2100