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Vill APPLICATION FOR SANITATION PERMIT Permit No. -;z---- (Complete ____(Complete in Duplicate) Date Issue. - :. Applicatiis hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicaon tion is made in compliance with County_Ordinance No. 549. JOB ADDRESS AND LOCATION------- cY'x? Owner's Name----- in-x2---De-'aXtini--------------- -------------- Phone---�-2� 7---- ------------------------------------------------------------------- Address Ft, 7�+ n ocL�__ t✓ lif Contractor's Name-----D. �1 �_nua-------------------------------------------------------------------------------------------------------------------------- Phone-------7-=-3Q_55 Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other El Clrnualen + Number of living units: _Q____ Number of bedrooms -_ Number of baths ____1- Lot size ----7QX_], Q_______________________._____ Water Supply: Public system M Community system ❑ Private ❑ Depth to Water Table _______ ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel [❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q Hardpan ❑ Previous Application Made: Yes ❑ No ©-- New Construction: Yes © No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 280 feet.) Septic Tank: Distance from nearest well✓---------------Distance from foundation_____- 1---------Material ___Ce-mC At-_�x, ul No. of compartmeni-s---------2--------------Size__f, ,S24_1�i4;________Liquid depth------�'_rc3=_-----Capacity-----800._____-_.rt;'� .• Disposal Field: Distance from nearest well---_--------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of lines--------------------------------- Length of each line--_---------------------------Width of trench--------------------------_-- Type of filter material--------------------------Depth of filter material-----------------------Total length------.--------------------------------- -- Seepage Pit: Distance to nearest well--- -- ------ ------------ from foundation______-..........Distance to nearest lot iine_____ 5_�__.-_� , �] Number of pits__1-----------------Lining material___back_____Size: Diameter----------- - Y'� �{�---t� Depth---2Q��,---------- Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining ma-aerial-------------_^____r_f--------------------- Size: Diameter--------------------------------------Depth-------------------------------------------- ------Liquid Capacity---------------------------gals. Privy: Distance from nearest well------------------------------------------------- from nearest building ❑ Distance to nearest lot fine_---- - --------------•---- - -------------- --------•------ � . Remodeling and/or repairing (describe):----------- 11at ,�.7�� _2% 11 :8 L-tiC tank Sy StEITI --------------------------------- 3 ---------------------- -----------------_____----------------------------------------_______________________________________________________________________________________________________________________________________-------------------- 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 rules and regulations of the San Joaquin Local Health District. (Signed)----------------De1ta--'------------------------------------- .By-- / JJ (�-.--- ---- -- --------------------------------------------------------------------(Owner ---and/or Contractcr) -------------__------ ITitle�-----0� ---------------- , ----------- .L(Plot plan, showing size of lot, location of system i relation to wells; buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_______ ----- -------------------- DATE- ---• ------------------- t. REVIEWED BY --- -------- ------------------------- ------------------------------------------- DATE------ BUILDING PERMIT ISSUED------_-------------- - --------------- DATE ------------------------------------------------------------ Alterations and/or recommendations:______________________ ------------------------------------ ------ --------------- -------------------------------------- _ r� �T t ¢ FINAL INSPECTION BY:--------IV>Id.- __t—1------------------------------ 3� r Y - Date- -------- --3 .� ,. 1�. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California B-9-2M 8-51 Revised W-2 i 00