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! APPLICATION FOR SANITATION PERMIT Permit No. -__._-. �r (Complete in Duplicate) /rS �- Date Issued ,FApplicatkon ss fie�eb made to the}San Joaquin Local Health:Disfrict for a permit to construct and install thew hgrein des ibec#. This application is made in compliance with County Ordinance No. 549. , l�, �� ',[sow.- AW/v$� lJOB ADDRESS AND LOCATION--- Owner's Name 4 Cllr L - _ + / E► Eh r ��l/ ------------ -------------- Phone-Ap-------�1 '(Address------------------------ ft - 1A :ll� . II onfiractor's Name_- `'�' f�g - � ------------------------------------------- Phone- -- •--. r� ' l<1 Installation will serve: Residence., partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---I _ Number of bedrooms -5__- Number-of baths __ v of size ------ .`__±� -`7 a -l________________ Water Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table _____ ft. " ll�; Ali haracter of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam t4ir Clay Loan Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ NoK. New Construction: YesgNo ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: s (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_�0___-__Distance foam fo ndation__�- ______-__.Material______'_____ ____________----___________ No. of compartments-_02-artments_ _Size �. ! - P f`r� - - , �'� ir-- -- Liquid depth__740-�r---------_Capacity_��CJ ^4� iso I Field: Distance from Weare well-_ Q-.-_Distance�r� foundation_ _ _�____Distance to nearest lot line________ i Number of lines---- ------------ g __ __ _ Length of each line_.-- C?______________ Width of trench______,_ - i ! Type of filter Depth of filter material----/If�/ -----Total length /-_Cp-o---- _ ------------------- seepage Pit: Distance to nearest well---------------------- Distance from foundation--------------------Distance to nearest lot line----------------- 1 . ! ❑ Number of pits----------------------Lining material-_--_-.-------------- -Size: Diameter-----------------------Depth-------------------_---------- esspool: Distance from nearest well______________ _Distance from foundation____.__.----------- Lining material------------------------------------- Size: Diameter--------------------------------------De th----------------------------------------------'-----Li Liquid Capacity -------- als. ❑ p q P Y- -------•----••- 9 (Privy: Distance from nearest well------------------__------ -_-----------Distance from 'nearest building---------- _____________ ❑ Distance to nearest lot Iine--------------------------------------------- - ------------------:-------------------------------- r 1 !I emodeling and/or repairing {describe) :------- t ----ow --fid-------0th-^_JS---- S-�_n_D/----- L.�/.� Ir - - -- --- ------ 1 ---•----=---------------------- ----------------------------------------------•--------------------------------------- L4----- ------- --------------------------------------------------------------------------------------------------------------------------------------------- I: Ihereby cerfif that I have prepared this application that the work will be done in accordance with San Joaquin County If rdinance 5t a s, ules and regu ti ns of the S n Jo qui al Healt Dis rict r � 4j__ -- [Signed} = _ � � d' ------{�or Contractor) -- -- -- - -- ----------- II� _By-------------------------------- -------------------------------------------- --- ¢ ------ -- ---- ------(Title)------------------- �'=--•------ (Plot plan, showing size of: lot, location of system in.relation t s, buildings, c.can be placed on reverse side). FOR DEPARTMENT USE ONLY a -' PPLICATION ACCEPTED BY---------.T -_------ ------ q7— DATE f �T ,REVIEWED BY------------------------------------- ------------------ -------------------------------------------------------------------- DATE----------------------------------------------- BUILDINGPERMIT ISSUED-------------------------------------------------------------•---------------------------------------- DATE------------------------------------------------------------- X11ferations and/or recommendations:-------------------------------------------------------------------------------------------------------------------------------•------------------------------- - --•---------------------------------•---------•------------- ----------------------------------------- - - ------------------------------------------ -----I-------I----------------------Z �. -------------------- ---------------------- ----------------- ------ --- ------------ --- ------------------------------------------------ ---------- -- A; - Y - ---- ----- - - ��jj r i FINAL INSPECTION BY:----� ---------------------- Date_ 7_-� -----�,/.- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street ' I Stockton, California Lodi, California Manteca, California Tracy, California is � - ES-4-2M Revisea ).57 F-P.CO_ 1