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APPLICATION FOR SANITATION PERMIT Permit No. z� 6" (Complete in Duplicate) 4 r } , Date Issued - - IS3 Application is hereby made to the San Joaquin Local Health District for a permit fo construct and insfall the work herein described. This application is made in compliance with County'Ordinance No, 549, JOB ADDRESS AND LOC ATION ___4L:-5-----_--__------ _ °<' -------------------------------------------------- Owner's Name-------------- 5_ _�$-------- _ _.._ + F► --------------------------------------------- Address - -Phone------------------------------------ --- - ; ,r.. �. - ti°' `---- ---- Contractor's Name------ ---L___�--- ------- ------ Phone-- � ¢ter 9 4 Installation will serve: Residence Aparfmonf.House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ __ Nu ber of bedrooms -_ Number of baths _�___ Lot size _--- . �,,I � ------------------------- _.. Water Supply: Public system Community system '❑ 'Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam e0E:1 lay Loam ❑ Clay ❑ Adobe ardpan ❑�, Previous Application Made: Yes E] No New Construction: Yes [ 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_________________Distance from foundation-------------------.Material--------------------_______-_ ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity----------------------- Disposal Fields Distance from nearest well_________________Distance from foundation-----------------_Distance to nearest lot line_____-________ � s ElNuer of 0 A ' YPeLength of fil er material-- epthofffilter lmaterial---------------- ----=otalthle length of nth --------_ --------------- _ Seepage it: Distance to nearest well_- _,--,---Distan mt n a ' n__—/A_ -----Distance to nearest lot�line_ [ Number of pits__AAq__-_----Lining mate ' I_, -- - -r_-Siz : Diameter__-__1-3____________.Depth____�{___ ____________ ____ Cesspool: Distance from nearest well_________________D st nce from f and ion___.__.____-____._.Lining material-,______-_________-- El Size: Diameter---- --- ---------- ----- D th -- -- - ------ --------- -----Liquid Ca t als Capacity -- -- -----9 _:. �_ 'Priv Distance from nearest well_____ ___________ ____ ____ __ ____ _Distance from nearest building___ ______--_- ------------------------- ❑ Distance to nearest lot line_________________________ ______ _ _ Remodeling and/or repairing (describe)_____________ _____ ___________ --------------------------------------------------------- ------------------- -------------- �--- ----*-"---'-------------- ---------- ---- ---- l;"�-------•= --------------------------------- --------------------------------------------------------- --------------=---------------------------------------------------------------------••--------------------------- I hereby certify that I have prepared this application an that the work will be done in accordance with San Joaquin County ordinances, State laws and les and regulations of the San Joaquin Local Health District. ----f - {! (Signed)---•-------- --- --� ---�-- - - ntra � --------- - -_(Ow r and/ Co ctor) BY: ---------------------------------------------------------------------------------------(Tlfle)----- -------------- (Plot plan, showing size of lot, location of system in "relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- ----------------------------------------------------- ---- DATE: REVIEWED BY -- - - ---------------------------------- ---- -- --------------------------------------------------------------------DATE__�_- BUILDING PERMIT ISSUED_-. ----------- DATE------- Alterations and/or recommendations:_______._ - --------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------•------------------------------------•---------• •� ------------------------------------------------------------------------------------------------------------------------------------------------------•-----------'----------------------------------------------------------- ----------------------------------------------------------------------------------------------------------•--------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------•---- • - f� FINAL INSPECTION BY:------- "_ �' - �,----_---- , ---------- Date------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" S+ree+ Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100 4