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•1 yz APPLI'CATION FOR SANITATION PERMIT Permit No.�1..-�__------ r° \ (Complete in Duplicate) y ----- App i Date Issued -_-- ------. _ -_ Joaquin Local Health District for permit to construct and install the work herein described. Application is hereby made to the San Joaq This li ation is made in compliance with Count Ordinance No. 549 1 ,� ¢ : I JOB ADD.RESS'LXN ,' OCA 'O - - . I f Owner's Name-'."":.``' : ¢¢ ----------------------- -------------------------------------- ----- 4 --- Phone !� e A --------------#-------------- -------------- - --------------- _ C'ontractor's Name=:�src�-.. ` -• Phone t I L' Instailatio 'will ser : Ressiidency. {, Apartment House [ Commerciale❑D Tr -er Cour',t ❑ Motel ❑ Other ff. g� � � C`` Nu bei ;4'living urSits: _i11 1 �!# C`lumber o bedrooms ..d-- Number baths ___ Lot s ze _------ -b / ---- -*�---•-------- i IE ` - ��el- i� i Water Supply: Public system E 1, community system ❑k Private Depth to Water Ta} le �ft- N1 � 1 Chaaractevof soil to a'gdepth of 3 feot: Sand ❑ Grave!❑ �a�ndy�Lo m ❑ Clay Loam 0 Clay El Adobe ❑ Hardpan E] !� Previous Application Made,. Yes ❑ Na ❑. New Construction:%Yes ❑ No ❑ TYPE OF(INSTALLATION{AND SPECII"ICATIONS: r 14_.1,i x y �+,s+eptic tank or cesspool P P.rmit�'d if public sewer--is availeb'I itliin 3 0 feet'.y Septi Tank: Distance from neare3T well-----------------Distance from foundation--------------------Material------------------------ ------------------------ . 10 No. of compartments------------- - ----- size's*1 it %%- --- i d t Capacity----------- Disposal F' Id: Distance from nearest v�wl__-s/L_- Distance fromfoundat n.. __..__"_Distance to nearest lot Number of line,--------------- __ _-.-_- 'engfh of each line--_19-7 �� idth of trench__ _-- ----_ _ ffg�, JJ e th of filter material__ --/[1 - Total l ---------------ZZ11, en th___---l..-". _.--._--.-_- Type of filter material-__ �__ p g ti Distance from foundatipr ---.Distance to nearest lot line---. __ Seepage Pit: Distance to nearest well--.= ❑ Number of pits----------------------Lining material-----------------------Size:,Diameter------------------------Depth_---- --------------- --------- Cesspool: Distance from nearest well-----------------Distance from.,foundation -------------------Lining material_-.____-_.--------------.--__._---- ❑ Depth_' - 1R__r "- -----------------Liquid Capacity- - ------------------------gals. Size: Diameter.--------------------- , , .Privy-... . .. --Distance.from,nearest�welL---,=- _- _ =---==-*-`-=--- Distant =from-nearasr-building------ ------------ ----------- ❑ Distance to nearest lot line- ---------------- ------------------------------------------------=-------------------------------------------------------------.-------- Remodeling and/or repairing (describe):------------------------------- -- ---------- --------"----------------------------------------------------------------------- -----•------- -•--------------------------------------------------------------------I--------------------------------------------------------------------------------- - --- ------- ------------------------------------------------------------------`---------•----------- ------------•------ - I hereby certify Chatj"4iVv—e prepare&this=applica�+on=and-t6$+ the �vb� will be7one in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the Saq Joa in Local He h pii5i fr� ct, { , (Signed " = - ------------------------- -----------(Owner and/or Contractor) Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ij%4 i A FOR DEPARTMENT USE ONLY APPLICATION ACC( PTED BY---- _ DATE — -- REVIEWED BY--------------------------------------- - --- - ---------- ---- ---------------------------------------- --------------- DATE------ -- ------- ------------------------ PERMITISSUED!-------------------------------------------------------------------------------------- ------------- DATE------------------------------------------------------------- Alterations and/or recommetndations---------------------------------E.- ---"-_ ") =A \ -------•- --------------- -----------------------------------------------------------------------"---------- ---------------------------------------------"--------------------------------------- !. __ -- ----------- --- ------------------------------------------------------------------------------ - ----- --------------- -"---------------------":- - -4.-•'_.-._-- -------------------------------------------------------------- --------- - ----- ---------------------------------------------- Date ----------------------------------.-.------ FINAL INSPECTION tBY .-•---- Date- - a If SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street' 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100