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APPLICATION FOR SANITATION PERMIT �I• Permit No_ ____ ___ ________ i /A 1 (Complete in Duplicate) / I Date Issued ...___j!t:._�� Applica}ion is hereby made to the San Joaquin Local Health District for a permit o c6h ndi II the work h re- described. This application is made in compliance with County Ordinance No. 549. �+ ` JOB ADDRESS AND LOCATION.-------'_ed�.6_.�Cy1_�_Z-------- -+�----------------------- = (L1- Owner's Name----- Q-/l---------•---!/Il _, ---------------------------- -------- ----- ----------------=-------------- ------ Phone------------------------------------ .............../ _4�'----------------- = :...:.._...... Address ------------------------------------:---------------------- Contractor's Name...__ -- _.. - :✓.1�.._.. - ---- ----------------------- ------------------------------------------- Phone----------------------------------- Installation will serve: Residence JR Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._ --- Number of bedrooms- --- Number of baths _ Lot size ----- _- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table fD_/ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe EX,Hardpan ❑ Previous Application Made: Yes ❑ No E- New Construction: Yes 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_ 4___1_Distance from fou dation____-A).!_Material____�C- ________� No. of compartments_-_- - .-.--Size ..��_eA__6 e---Liquid depth__._----f2.:.0-------.-Capacity__. �> ___ Disposal Field: Distance from nearest well _`._Distance from foundation---- Q. __...Distance to nearest lot line__ __ __ Number of lines______________ __ _ ___________ Length of each line___________ .- Width of trench.____ ��_..__________-_ �` g � ...... f Type of filter rrtaterial_ ..___51 Depth of filter maternal-..---�._45...__.Total length________ ______________________ Seepage Pit: Distance to nearest wells __.___Distancefrom f yndation._-tom--____._..Distance to nearest lot line____el-__--- K_ Number of pits-------- Lining material---- .---Size: Diameter______ 5-'.IDepfh_..._�_;�_____________ 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.---------------------------------------------- -...-•--••------------------------------------------------------------------------------------ Remodeling and/or repairing (describe)___________________ _ _ -----------•---------------------------------------•----------•-------------------...-----------------------------------------------•--------------------•------------------------------------------------------------------- ---------------------------------------------------- -----••--------------•----------------------------....----------------------------------.-...-----------------------------••-----------•-----------•---------------- I-hereby certify t ave prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, a rules and regulations of the San Joaquin Local Health District. [Si --------- ------�------=< - ------------------------------- ------------------------ --------(Owner and/or Contractor)` By:--- ----- �--- ----------------------[Titley- / ------------------_------------- ...... (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--------_`yrs___------ ----------------------------------- REVIEWEDBY------------------------------------ -------- -------- ------------------------------------------------------ DATE---- ---------------:------------------------------------ BUILDING PERMIT ISSUED------------------------------- --- DATE-- --------------------------------------------------- ATE- .. Alterations and/or recommendations:------ - -�--�---- ------------------------------------------------------------------------ -- ...... 1, -- ------------ ... ... • ------.-----•--- •......... ............. ::-------------------------------- ------ -. - --- - � --- ::: _ ------------------------------------------------------------------------------------ ----------- ----------- ----------------------------------- ---- - -- -- ------------------------ FINAL INSPECTION BY:----- - ---- --------- Date....`---------�--~- - --- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California i ES-9 145446 ATWnOO