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► ' / �' f� APPLICATION FOR SANITATION PERMIT Permit No. in Duplicate)(CompleteP Date Issued . � ---- Applica{ion is hereby made{to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549,E I (/fly --� , JOB ADDRESS AW LOCATION.. -1- Owner's Name------ ------------- ------ ---- ----- ""G►------a'p--'+k--------- -------------- ------•-----• ----------------- Phone--- - Address--{ --•---o'•-------- --- -------------- -------- ---------------i--------------------------------- _ Z ContrY0 ----- i Phone ` - - . actors .Name-- .... Instaliation will serve: Residence 2� partment,Housax❑ Commercial' ❑ Trailer Court ❑ Motel ❑ Other ❑ i i Number of living units: _-V Number of bedrooms __7,.-Number of baths _�___t Lot size -----6. __._f-- - ----------- ----------- Water Supply: Public system Community-system-❑' Private ❑' Depth`to'Water Table".,,0ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ElNo New Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: l y (No septic tank or cesspool permitted;if public sewer is available within 260 feet.)' Septic Tank: Distance from nearest welle '+ Distance from foundation_y_,/ _.Material____________________________ _..�______- No. of compartments__-, �++. ---Liquid depth --------Capacity---�41 . .____ Size__ Disposal Field: Distance from nearest Distance from foundation.--_'-.2— Distance to nearest lot line___}_......... #t f �V Number of;tines___________. {Length of each line__ . _____�.______Width of trench._ _�4_4f_t!----------- Type _• =; - ------- --- 4 Type or filter material-.?'<-__.-._ _ _ __,Depth of filter material_____ _ ________.._Total+lerigth�-�_ �----_ Seepage Pit:'-"`' Distance to hearest'wel#. Distance f om`fo ndation.�::_ - Distance to snearesLAo'fRlin x. Gesspool: Distance from nearest well_________________Distance from foundation--..____....______..Lining material-------------------------------------. 0 Size: Diameter-------------------------------------Depth------------------:------------------ t-----Liquid Capacity----------------------------gals. Privy:E Distance from nearest well.--.-----------------------------------------'---Distance from nearest building__.--------------------------------------- Distance to nearest-lot line.-'-__. ❑ ►,._ - m --k- ,. "'°_'"_._- _.. g repairing t I Remodeling and/or re airm (describe): -'----'------------ --- -x-- - --------------------------------...---•---•---=-=-----._.._..-----------------....----------------------- ----------------------------------------- ------ ----------------------•------------------------------------•------------------------------ ------------------------------------------------------------------- E 1 '___ __________________--_-_.________-___________.____________----.......-_______________---_-________»..-..._______•__--_---__-._______.._..-...______-____________________________._______-___________________.--------------------------------------------------- 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. `q (Signed)-•---- --- -------------------- -- -'--•'-----�-- •- ' Contractor) - -- --------•--_----- ------------.✓g_ ;- ---------------------------------------------(Title)---- ---------------- (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 r APPLICATION ACCEPTED BY_-_. '"" -------------- DATE ------------------------------------------ i �REVIEWED BY----------------------------------- T ------------------- DATE--- � DATE ---�'" ----------- BUILDING PERMIT ISSUED....----` = ------------------------ ---------- ---------------------- ------------------ --- DATE and/or recommendations:-----__.__._-:__�_ �..` ------- v l r -— - ----=- -------------------------------------------------------------------- ------------------------- --------===----- •--•--------- -- ----- -------..._...- •------- FINAL-INSPECTION-BY:-._---A? .:" ---- _4., ..Abate----------- --- -. = -------------------- "` _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M Revised W-2100--1,_ '