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APPLICATION FOR SANITATION PERMIT Permit No, _._ .7.7.d.. (Complete in Duplicate) 7 �y Date Issued ..... ...�a�. Applica+ion 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.,g .,_.,4- i_ 4f1�v�Jrt-- .---" ��.. Owner's Name----------- --- ---------------------------------------------------------------------------------------. Pone----------- -------------_---- Address.....-----•------.lkz ....../k... . - ' -• ..... -- Contractor's Name.......... . --••--- > u i _--- ---•.. Phone me ,1`� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ../_.. Number of bedrooms _R-. Number of baths . _ Lot size __ � yi(_ � _�._ ---- --------- ------ ----•----------- Water Supply: Public system ❑ Community system ❑ Private �epth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No,�`ir New Construction: Yes [f.]-"qo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) i ,tea Septic Tank: Distance from nearest wed_ -- _-Distance from foundation__ _________.Material -_X� __ "e-ob, No. of compartments.._- .'. . -.____..___Size..-__,�"-_�W.__-Liquid depth__..___ .__-4 Capacity....4f,�e--__- 01 Disposal Field: Distance from nearest well__;-p-----Distance from foundation•_Ske� .-___.Distance to nearest lot line........ Number or' lines--------- ________________ Length of each line_____ __,E,e�.�___ _._.Width of trench...... �.��-_-._--_-__----_ Type of filter material__/_.___ epth of filter material-----lk"------Total length........,0�_°-----_-----------. Seepage Pit: Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line................. ❑ Number of pits--------------- ------Lining material.......................Size: Diameter-----------------------Depth--------------------------------- Cesspool: _._.-_._________--_-______---.Cesspool: Distance from nearest well____-----__.____Distance from foundation.------------------- material___----------------------____________. 1 ❑ Size: Diameter-------------------------------------Depth----•- ---------------------- ------------------Liquid Capacity............................galsk Privy: Distance from nearest well----------------------------------------------__Distance from nearest building--------------------_............ .._... ❑ Distance to nearest lot line-------------=----------- ---------•---------------------•-----•----•------------------------__---------•------ Remodeling and/or repairing (describe) ----• . ---------•-------------•------ ----- -•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 1 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. f (Signed)--------------- � / ------ ---------------------( s+ Contractor) ---------------------------------- (Plot plan, showing size of lot, to ion of system in relation to wells, buildings, etc., can be placed on reverse si FOR DEPARTMENT USE ONLY dP1.lCA ► GSI ACCEPTED BY ------------------------------------------------ .......................................... DATE_A--............... ............___............... REVIEWEDBY ------------ ---- --- ---------- - ------ DATE.-V------------- ------•------------------------ BUILDINGPERMIT ISSUED-------------------------------- ----------------- -------•-......................................... DATE.......qA------------------------------------ 4:5— Alterations and/or recommendations:-------------- ------------------ ....................................................... .-.-.-.-.--..--..-.-.-....._.X.._......-..-.-....-.............------------------------------------------------------..-----•----------------------------- .------------------------------------._...--------------------------•------------......----•--- „i< ' �Y --, t .,.._ .... .......................... ..... FINAL INSPECTION BY:--------------- :_ � -: _ Date..... 1- �--------------------------------------- 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 145446 A-(WOOD