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APPLICATiON FOR SANITATION PERMIT Permit No. j (Complete in Duplicate) / ate Issued �� /5 Application is hereby made to the San Joaquin Loca{ Health District for a permit to construct and install the wofk herein described. This application is made in compliance with County Ordinance No. 5 9. ceJ�.`/A/ JOB ADDRESS AND LOCATI/ON_f •9sf'3 __5__r_si/ --0- -� --- -t�!,±-- - -�d�t?�r ------------- c _�/ i Owner's Name---,Z- 416--- --------- Phane-_ -_�_ � ,� �� --------------------------------------------------- Address-----------.(9e iV-----. .._Q, < - ------ Contractor's Name-- ! f-a _f' ----- ------/&� ------------------------------------------ Phone_-F--0.-4,0--7------- Installation will serve: Residence 5 partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ` Number of living units: -,/---- Number of bedrooms _-a___ Number of baths -,Z__ Lot size _/_'�t�' _.1�__��d____________________ ___ Water Supply: Public system li9Communify system ❑ Private ❑ Depth to Water Table -4--- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 21"H--ardpan ❑ Previous Application Made: Yes ❑ No [ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND.SPECIFICATIONS: (No septic tank or cesspool permitted if pt lic sewer is available within 200 feet.) Septic Tank: Distance from nearest well_ a�P____Distance from foundation___/0.1____-_-..Materia}_ D-VC"--j&--c:?.-, -- D/ No. of compartments________ Size_� ""r-6,2------Liquid depth------ �r Capacity- Disposal Field: Distance from nearest well-lYQ_4/e__._Distance from foundation_--2-Q-........Distance to nearest lot line/_ ";_-------- _-- ®� Number of lines----------0 �_�� -- -------------Length of each line-------- of trench----- ---------------- Type Type of filter material_f/�-_/&A_-Depth of filter material-----/- ''_.......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 nearest building-----------__�^_:._.:___— ------------ Distanceto nearest lot line--=-------------------------==----------------- ---------------• --------------------------------------------------------------------- Remodeling and/or repairing (describe):--------- Gc? 1►V _ ?-df - (� -------------------------•--------------------------------------•-------- -------------•--•---------------•----•----------------- --- h _____ _________________________ ___________________________________________________ ______________________________________ _________________________________________________________________•_-_A _____________________. __ \ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County 1 ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. I � i Si ned /A � /Y r 0&.75 /OC _ towner a d/or Contractor) ( g BY:----1' � `= � ---------------------------------------------------------------(Title------ - --- �- (Signed) - -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on'reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ DATE_ ,- ------------------------------------------------- REVIEWEDBY y `------------------------------------- --------------------------------- DATE �---------------------------------------------- BUILDINGPERMIT ISSUED------ =fl ------------------------ -------------------------------------------------- DATE-------------e------------------------------------------ Alterationsand/or recommendations----------------------- ------------------------------------------------------------------------------------------------------------------------------------- -----I---------------------------------------------------------------------------------------------- ----------- ----------------------------------------=------------------------------------------------------------------ w -----------------------•----------------------------------------------- ------------------------ ---------------------------------------------------------------------------------------------------------------------------- ----- -------------------------------•------------------------------- ---- I �. �.. '�"-�"----------------- FINAL INSPECTION BY----------------------------------�%Gr----- Date--------- _�c�__�--'4i-`-�----- I - 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 E5-4-2M 8-51 Revised W-2100