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a � - APPLICATION FOR SANITATION PERMIT Permit No. _____�_.l._- • - [Complete in Duplice+e] D .S' /�, F • w+n: �.,y..•.w-.- rr -.T c �v. .. �::.rw - c�.4 �M'+.. ..x .,v. - r __ _--•-- F., ate Issued �". Applica�ion is hereby invade to the San Joaquin Local Health Districf for a Psermit to construct and install the work herein described. This application 'is made in compliance with County Ordinance No. 549. h &`, 9# 75 JOB ADDRESS AND LOCATION.---/ ----------------------------- ------ ----------- - - --._�f..------------- Y Owner's Name-------s i. ..� ..... -- ---•------- --- ----------------------- ---- P -----.----- Address I �_ ., ---.. - --------------------------------------------------- I , _ _ ----------------------------------- --.....------ f----------------------"--_------- Contractor's Name---------� -�- ---------=-------------•-- ------------------------------••------------ - Phone�1-- --`----=Z Installation will serve: Residence 5d"Apartment House ❑ Commercial ❑ Trailer Court ❑'- Motel ❑ Other ❑ Number of living units: :___ Number-of bedrooms - Number of baths _ _____•Lot size ___% _'_X_le_a'___________________________ T Water Supply: Public;system ❑ Community system ❑ Private Depth to Mater Table 4¢_ft. Character of soil to a depth 'of 3 feet:'4 Sand ❑. Gravel ❑ Sandy Loam ❑ Clay Loam ❑. Clay ❑ Adobeg Hardpan ❑ Previous Application Made: Yes ❑ No 0 New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: No se +ic +ank•or cesspool permitted if public seweris available within 200 fee+.)} — - per_,• ._.«Ts.. .�.. _ _, 4 � - : .• Se tic Tank: Distance from nearest well________ _______Distance from foundation_-____-_,__,_______-Material_______=_________________-_-_______.________- _ t No of. compartments = 5iie=_+_. _. --------Liquid depth--------=--------- ---. Capacity--------- _ �.. ` Disposal Field: Distance from nearest well__-�s_____Distance 4, rr� foundation___________________. Distance to nearest lot line.....__.......... Number of lines______________ ---------- _Length of each line_.__.__.. s�___'-______-Width of trench____._�_`�_-- I ----------------- Type of filter material____S_�1 .____Depthof filter material__# :�_ �-------- length__.__ s_�______---- ______________ Seepage Pit: Distancesta ro rFb Distance to nearest lot line_________________� �s g Deptn ------------------------ �[r Number of pits.__.__,_l-_:__,_ -__Lihin mat sal-____ ____ '`__ _'-.Size• Diameter__.____�:/r _ Cesspool: Distance from nearest well____ 7----- istance from ion----- --_._+-------,.Lining material_____________________________________. Size: Diameter ` ? De "' h' Liquid'Capacity------------------------• -gals. Privy: Distance from nearest well-------------- -__-- _.:-----------------Distance from nearest building_______----------------------------------- F 1 ❑ .• - ---- ---- -- ------------------ --------------..� .-------------------------- ----- --- -` Distance to nearest,)�t-,line:_:�___,y_______F___-_-_:___ i � • I Remodeling and/or repairing (describe): //` "' ---�- -------------- "'rte r�- .._.. zldL41.. - --- -- - - --- -•- '. ----- ----- -- ------- - --- -- •-- ----------- - --- ------------ ----- ----------------------=------------------------------------------•--• _..._•---•---------------------------------------------------------- 1 here cer+ify that I have prepared this application and•+hat the work will be done :in accordance with San Joaquin County ordinances, St e'laws, and rules and regulations of the San Joaquin Local Health District. --------------------- - (Signed)-------- ----- ------•_-, - (Ow and/or on rector) n C t By:------------- W (Title) (Plot plan, showing size of lot, location-of s tem-in relation to•w ells,-buildings,•etc., cam be placed on reverse side). FOR DEPARTMENT;USE ONLY . , ej APPLICATION ACCEPTED BY---- W•- '! `"----------------------- DATE. --� 4` �° -•------------- REVIEWEDBY_---------------------------------------------__V---------------- ----------------------------------•-----•------------ DATE-------------------------- ----------------------_- PERMITISSUED----n--------------=------------------------•--• -•-------------------------r-------------------- DATE----------------------------------- ----------- -------•- Alterations and/or recommendations:------------------- ---------•------•-=-------------•----_--` _................ --------------•------------•--------- ••-------------------,-------------------•---- ----------------_----------- --------------------------------------------------------------------------------------------- ---------------------------------------------- --------------- ------------------- --------....._--------- -------------------- -----•--- ------•--•-------------------------------------------- i ` .,_ `I r ► Dafe=-14 FINAL INSPECTION BY:.-.-. .--- � == SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M Revised W-2100 _,