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x el-A APPLICATION FOR SANITATION PERMIT Permit No. . _ a'" (Complete in Duplicate) 4-LI i Date Issued 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. ` 8_('7C JOB ADDRESS AND LOCCATION--- ••- K - ---- Owner's Name------------------C7•!�-d-'---•----•--4?4,1/g_-�. ------------------------------------------------- -------------- Phone------------------------------------ Address -------------------------------•----------•------•---------------•--------------------------..................................................... Contractor's Name.............................. d •---------•--------••--------------------------------•-------•-•---------------••---•-- Phone----4`� 4� 4�3j ..__. Installation will serve: Residence U� Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:___-____ Number of bedrooms ___y_ Number of baths I..... Lot size ___-___S�_�C.f/O Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9 Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well---------------- Distance from foundation-----�A_-------.Material---- - � _..---------------- No. of compartments__._____y----------Size___ xgx_..��_,___Liquid depth___�'_O___________Capacity______L _____ Dis os I Field: Distance from nearest well__`'-"'-_-:_Distance from foundation_____0_.______.Distance to nearest lot line....._Jr__��___. Number of lines______..____7...................Length of each line__________GO2 *-________-Width of french-----------_LW1_.---------- Type of filter material_- ,��i-___Depth of filter material--------19----___Total length............_Zrz)____________________ Seepage Pit: Distance to nearest well______----------------Distance,from foundation....................Distance to nearest lot line____-____________ 0' ❑ 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------------------------------------------ 11 ____. .____--_..______________-___-_❑ Distance to nearest lot line--------------------------------------------------------------••---___---•-------------------------------•---•- ----------------------------- Remodelingand/or repairing (describe):--.---------------------------------------------------------------------------------------------------------------- •----__--------------_--.......... -----•-----------------•----•--•-------------•--------------------------------------------•------------------------------=---•-------------------------------•---•----------------------•--------------------••-•-•------- --------- ----------------------------------------------•----•--------------------------••------------------------------------------------•----••-----------•--------------------------------------- ------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules and re tions of the San Joaquin Local Health District. (Signed)--Y.------ ............... -------_-'--- ------ -- --" ----j- ----- ---------------•---------(Owner and/or Contractor) ?_'1_1------ -- - - 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---------- +�r REVIEWEDBY---------------------------------- ----------- ---------------------------------- DATE------------------------------------------------------- BUILDING --------- -----------2-- ------------BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------ Alterations and/or recommendations:............................................................................................................................................................... . , , t - 7 _ ._ ___ _._- _ _ _ .__ ___- . j P� � ma - • -._. _ _ _ -____ a- -- -- ------- --- _. __ ... — --- - •------ -- :------- _ _ .. S y: --------- --- -- _ r -- •---••-- FI 15f ECTBY:___ {--------- ------ Date_ ------ ---------- j- -_ ----- .......7� 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 ES-9-2M 10.52 Revised W-2100