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1� C� APPLICATION FOR SANITATION PERMIT �v Permit No. __4.�.-1--- Z. l (Complete in Duplicate) J l Date Issued313 I� Application is hereby made to the San Joaquin Local Health District for a per it to construct and install the rk herein described. This application is made in compliance with County Ordinance No. 549. /05 Opp, XOa" JOB ADDRESS AND LOCATI iN _ed_fit-+__.__�Y!P`--"+ -_ Owner's Name----------- �." _ Pho ----------------------------------- Address---------------------------------------------------- 1 -------4-a------ ----- +fie Contractor's Name. -----------��------------------------------------------------------------------------------------------------------------------------ Phone---------------------------------•- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel❑ Other ! Number of living units: Y___ Number of bedrooms*3--- Number of baths fl-AW-Lot size ---__,- ------ ___ ._+i_i�__►_( _________________ ,j Water Supply: Public system LU Community system ❑ PrivateAl Depth to Water Table _ _a ft. Q Characfer of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoamX Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ i Previous Application Made: Yes 0 No ❑ New Construction: Yes ❑ No ❑ 4 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___'.a_______.__Distance from n ation__fd1y�___.Material__- ._._________________________ Xf No. of compartments---_------ "---------Size----?X'_3__ 0------Liquid depth----sl--------- Capacity_Ca acct ��- Disposal Field: Distance from nearest well__0 --__.Distance from foundation __.__.~_Distance to nearest lot II n, ____ `_._... Q ® Number of lines---------- ____ -_--.___�.__Length of each line---- �_>-_ _._Width of trench---.R- `---__ Type of filte`r material�� - ..__Depth of filter material____/ ��____._Total length_______/�0_f________________ Seepage Pit: Distance to'nearest well----------------------Distance from foundation-----------.--------Distance to nearest lot line---------------__ M Number of its______________________Linin material:_____._______.__. ❑ i P g Size: Diameter Depth---: " 11 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: r Remodeling and/or repairing (describe):---------------------------------------------•--------------•--------------•---------------------------------------------------•------------------------ ---•-----••-----------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------------------------------------- - � I ----------------..-------------------------------------------••------------------------------------------•--- -----._ ........--•--------------•--•---------•--------------------------.----------- ------------------------- ------------------------------------- ------------------- --- _ __ ___ 11 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. c (Signed) - - --- ---- ---- ---------------- ----------------------------------------------------------------------------(Owner and/or Contractor) By--------------------------------------I------------------------•---------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). DEP RTMENT USE ONLY ; APPLICATION ACCEPTED BY-11------ DATE--- -a-- ------------------ REVIEWEDBY- �M----- --- --------- ----------------------------------------------------------------------- DATE----------------------------------- BUILDING PERMIT ISSUED.......I--------------------------------------------------------------------------------------------- DATE------ --------------------- -------•------------------------ Alterations and/or recommendations------------------------------------------------------------------------------------------------------------------------------------.---------------------------- ----------------------------------------- { N Il IM �I ---------------- ------------------ --------- ----- M----•-------------------...---------------------------------------------------------------------------------------------------•------------------'--------------------- FINAL INSPECTION BY:- 1 ----- -�--'��-- ----------------- Date- ------ - --4VI,/ A;7_3.--------- --- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street S+ock+on, California Lodi, California Manteca, California Tracy, California ES---9-2M 10-52 Revised W-2100 1