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1� r APPLICATION FOR SANITATION PERMIT Permit No. e� 1 . " \ (Complete in Duplicate) Date Issued _._..l�O✓1��__ 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. JOB ADDRESS AND LOCATION_10 __.,6_ .:_. ,f/ ,5 -- ---- Owner's Name- , &.46Wx.01_/1' .'---- -- --------..-- --- -------- -------- -------------- Phone--=----- - OK Address - � /p�d f '/6,0 ----------------------------p-------------------------------; ----------------------------------------------------------------- Contractor's Name---- ---.--- ---------------- Phone------------------ -------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: .-.__ Number of bedrooms..-_ Number of baths _?�_-_ Lot size `___/ f` .................................... r Water Supply: Public system ❑ Community system RR`7'rivate❑ Depth to Water TableAr r ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe g?- Hardpan ❑ Previous Application Made: Yes ❑f No �New Construction: Yes R�—No ❑ FHA/VA: Yes F--No.❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-AV istance from foundation----�o_--_---Mat ri�f ------ ------- _ No. of compartments...1Z. .. _ ___� Size ��__ Liquid depth . __...._. _Capacity....A?t3_ Disposal Field: Distance from neares we �+ W Distarice from foundation �� .Distance to nearest lot h��_______.._ Number of lines---- _. Length of eacs _h line_& ____ 4? .Width of trench--_- . -_-_--___ Type of filter materia . Depth of filter material-A?.`'`___._Total length-._-- �__ `.. /_ __Q Seepage Pit: Distance to nearest wel/X�X/,0__2_Distance �om_10fou.n-fdS tion_- X0 `-___ parte to nearest lo�t�j line--/es Number of pits __ ____Lining materiae_ _ ze: Diamete . __....__.Depth...__%�� y P 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.-__ -_-____. _____ _---___. ❑ Distance to nearest lot line=----- ------------- --------------=---------------------------- ------ -------- i Remodeling and/or repairing (describe) +5�� / f_� „�' �,. _ ------ -- --------------------- -------- - -- L4�74_- ---.------ - --- -- - - ------ i --------------•--------------•-------- ----------------------------------------------------------••--- -------------------- - -----------------------------------•---------------•--------------------------------•--- 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 r es and regulations of the San Joaquin Local Health District. (Signed)--- ------ ------------------------------------------------ a "Zontractor) By:--_--------------- -- -----------------------------------------.---------(Title) �� ---- (Plot plan, showing size lot, location of system in..rela4ion to wells, buildings, etc., can be placed on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- -- DATE--------- ".2/ REVIEWEDE I IS ---------------------- ------------ ---------------------- DATE BUILDING PERMIT ISSUED ------ ---- - ------------------------ DATE------------------------------------------------ f Alterations and/or recommendations:------------------------------------------------------------------------------------------------------------------------------------------ ------ --------------------- ----------- -- --- ------ - ------- - �_ ....... ��- - - ----- FINAL INSPECTION BY:. ------- - ---=- ----- Date--- `)_----..�_ -�--. r SAN JOAQUIN LOCAL HEALTH DISTRICT 1 130 South American Street 300 West Oak S+rent y 132 Sycamore S+ree+ 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 FY,CO.