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APPLICATION FOR SANITATION PERMIT Permit No. _. Q...�1. n Are (Complete in Duplicate) Date:Issued ..��_�• V 3 Applica4ion 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. JOB ADDRESS AND LOCATION............./6-----------�. --,&_7__A.1exV .... Owner's Name_.. V C1 tb�r� �. / L.1.. Z ---------- ------------------------ ----------------- P1one1�. Address.............................p�-.a--/-------------- -------- Contractor's ------Contractor's Name..------•-�--------,4-1 --------------............................--•.....----------------.... Phone--•-------------------------------- Installation will serve: 'Residence U3`4'Apartment House ❑ Commercial {] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-----: Number of bedrooms ---�_. Number of baths .../.. Lot size .._...�p --__. :- ; - Water Supply: Public system Rr,Community system ❑ Private W Deptlt.to Water Table ' __ ft. Character of soil to a depth of 3 feet: Sand,0 Gravel ❑ Sandy Loam M Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: p (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Cc I(t"'1 -- Septic,,Tank: Distance from nearest well 4-0Distance from foundation._,f�__--__.Mateal-----(/A/_.,At�Ns?.4S,7lhL--------------- No. of compartments------------ -----------Size..Ad _3 L...........Liquid depth_._._./_-?-------Capacity_.-____t�[�'L'?.. Dispose Field: Distance from nearest well.-* _Distance from foundation ,D ._Distance to nearest lot line------<--- Number of lines ______� . /.�-:._ .Length of each line,------------ _.Width of trench ....-.."�___. _ � Type of filter materiaL__._aCQ�,L -De Depth of filter material___... _ g Yp p - �1�/_------.Total length ---------------- Seeps Pit: Distance to nearest well-7Ad---{...._Distance fr foundation_. `Dist nce to nearest lot lin-"`�`- Number of pits___ ____ ____ ___Linin material... Size: Diameter__----- - " ............ �—-- g --------.Depth------- -- ----- Cesspool-, Distance from nearest well-----------------Distance from foundation--------------------Lining material-___:__--__•-_______________________ ❑ Size: Diameter--------------------------------------Depth---------------- . ------ •------- ---.-Liquid Capacity............................ Privy: Distance from nearest well_:`___________________________________-____Distance from nearest building-----------------------_------------------ 171 _---- --________❑ Distance to nearest lot line-------- •----------------- ------------- --------------•------- ------------- Remodeling and/or repairing (describe)------------------------------------------------------- --------••- ----••....... . a a •-'as ..................................y _.... ?ft.ac.�Ccc_�.��. .c=a 4 ---- ----------------------------------------------------------•-----------•----•--------------•---------------------------------•------•------•--------...•..-----------------------------------•------------------------------- 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. ,fie , (Signed) - (Owner and/or Contracforj --•- _--------------------------------------(Owner -----(rifle)-----------------------d 1UA/....... -- (Plot plan, showing size of lot, location of system in relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY......... ---•--•----_.. DATE ,} J� ------------------� REVIEWED BY---------------------------------- - -------- ---------------- DATE---•--------- -- -1- 2 - BUILDIN'G PERMIT ISSUED----•-----------•----- --•--------------•..._--•------------•----......--•-••..._. DATE---------------•-----------------------------------•--•-•---. Alterationsand/or recommendations:..................................................................................................................--.......................................... -------------------------••- - - ------- ----- .... --------------------•---------------------------- ------ - - ----- - . - - ---------- -------- ------------------ FINAL INSPECTION BY:........... ------- --•--- Date-------------- s 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 W-2100