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yr 11 APPLICATION FOR SANITATION PERMIT Permit No.,,:s3 7( 0 NI (Complete in Duplicate) " Date Issued ap.1i7on is'hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 4' plication is made in compliance with County Ordinance No. 549, • /" t JO ADDRESS AND LOCATION--------- ----- Owner's Name - :i' chi Ph ne.-----4.71 11 � ' " � ----------- Address---•--------------• = = ? 1�?c� �r - i_ftNr00P� - -f_ -------••-- ---- ' Contractor's Name. = tl . -- ---•---- -- ---- - --- - - --------- Phone------- Installation will serve: Reside'ncee Apartment Le ❑ Commercial Trailer Cour} ❑ ❑ Motel ❑ Other ❑ � Number of living units. Number of bedrooms __- Number of baths __-_-___ Lot size ____._.� Water Supply: Publi -------------------------------------------•- J c systema( Community system ❑ Privatee❑ Depth to Water Table __..___- ft. Character of soil to a depth of 3 feet: 1Sand ❑ Gravel ❑ Sandy�Loam ElCIay'Lo`am E] Clay E] Adobe Hardpan E] Previous Application Made: Yes ❑ No, � 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 weld__ _____________Distance from foundation------------- -----Material----.----------- -------------------------------- No. of cor;partments- --------------------Size---- v-- -- -------- - - - -- Liquid depth--------------------------Capacity - ------------ Disposal Field: Distance from nearest well.'..-----------..-Distance from foundation--------------------Distance to nearest lot line__________.-_____ ❑ Number of lines----`-------------------------------Length of each.fine------------------------- Width of trench----------------- ----- Type or filter material---------------------- -Depth of filter maferial--------------- -----Total length---------------------------------------- Seepage.Pit: Distance to nearest well-----__--------------Distance from foundation-------------- __..Distance to nearest lot line_._-------------- f ❑ Number of pits-------:"------ -----Lining material---------'-----------Size: Diameter----•-------------- - - r Depth------ -------------------------- Cess ool- Distance from nearest well___I� _ _-_.___Distance from foundation.-- �D_- ---..Linin matperial........... t ---------------- -------------- --- _ g Size: Diameter = -----------�_"Depth-------- ---------------------------Liquid Capacity.. -----------gals. Privy: Distance from nearest-well I ________________________Distance from nearesr building ❑ Distance to nearest lot line------------------------------------------------•------_ t Remodeling and/or repairing (describe)_______________________________•-_------- --------------------------------------------------------------------- --------•------------------------------ -----"--------•---- ------•-••---------------••-•- = - �----------------- ----------------------•---•---------•----------�`"-.------------------•----------•----•---------------•---- _. herebycertify that I have � .. -----��---------- -- - - ---`- -------------""" y prepared this application and that the work will be done in accordance with 5a Joaquin Coun ordina s,4wate laws, a d rules and regulations of the San Joaquin Local Health District. a (Signed) - - - ----- ------- ------------------------------------------' {Owner and/or Contractor] .� W { • ---------------•--------------;--- ---------- -----------------------------------------(Titile)---------- -------- (Plot plan, showing size of lot, location of sysfem"An relatron.to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- -------------- ----- -"-- -- -- DATE_ - c-� _ REVIEWED BY -c-- �------------- ------------ ----- --------- -----. DATE----------- ----- BUIL DIN PERMIT ISSUED------'--•---------------------------------------------------------------------- ---------=----------- DATE----------- --------------- Alferations and/or recommendation ._______"__ ----•- -------------li '-'^' 1 = :- --- ----------v�-_--:`---------------•- ._: _ ___::_:: ; - ---------11h.9 - ------- ------ •------------ - 7----- -----•------------- h - - -.--- - ------ --- -------------- --- - . ._ fl�c .r.�i : . cr�eJ FINAL INSPECTION BY:------ _ Date.......-- - --- ---.---"-__ • I ----------------------------------- SAN _ 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 1052 Revised W-2100 11 jjSLp /�