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��f1� APPLICATION FOR SANITATION PE � Permit No. ________ ____________ ` �� , (Complete in Duplicate) 7 � 4,�� 11 Date Issued Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION------ :- ------•-----...----- ---------------------------------------------------------------- ---------------------------- Owner's Name-- R----- 'L� ----------------------------------------------------------------------------------- -------- Phone./--� C.2-? � Address--.........--2.1- Q......F--------A z_r ----------------------------------------------------------- Contractor's Name-----------f-(7------- ------=4� 73�,_.24_ -------- -------------•-- Phone----------------------------------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ TrailerQ, Motel ❑ Other ❑ Number of living units: __/__- Number of bedrooms -----/_ Number of baths _-l_-_.- Lot size ---./90- 'X-�'�.---__-•----------------------- Water Supply: Public system � Community system F] Private ❑ Depth to Water Table .Yq7ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No E� New Construction: Yes i No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if pu lic sewer is available within 200 feet.) Septic Tank: Distance from nearest well Distan,cg from foundation �.0---•----- .Mat rial--- .G . No. of compartments_-_.___.��____._--Size.... _n_ = -------Liquid depth__-___--------------Capacity_...)z ______ 1 Disposal Field: Distance from nearest well._M1A,4._Distance from foundation-___(rt�----------Distance to nearest lot line.__+_____,__ Number of lines_______.______ _______ ______ Length of each line_____:__--__._--_.--.Width of trench____,_____. __._ __________ _ 1, -- Type of filter matenaL ___'' 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-__-_____--__.__-___-_.-._.___.________--. ❑ Distance to nearest lot line------------------- --------------------------------------------------- Remodeling --•-----------------------------------------•-•--Remodeling and/or repairing (describe}: - h ------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 and regulations of the San Joaquin Local Health District. (Si ned -- �� 9 )--�---- -------•--•----------------- ------- --------------------------------- - ---•------------- caner an /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). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------- • DATE......... REVIEWED BY------------------------------------------- - -------------------•------------------------ DATE--------- l(- --- -------------- - - -- BUIL ING PERMIT ISSUED - ---------=----------------------- DATE--------------------- ------------------------------------ - -n / T -ndati - --------------------------------------------------------A to ations an or�re � - /1� ----------------•--------...--•--------------------•--•--•--------•-----------------•-------•-------•-•------•- I --- -------------------------•--------------------------------------------------•----------------•---•-----------------•----------------------------------- -•--------------------------------------------•----------•-------- FINAL INSPECTION BY:------ ---------------- Date K 7, ---------------------------------------------- r 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 ES-9-2M - Revised 1.57 F-P.CO.