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v APPLICATION FOR SANITATION PERMIT Permit No. ___fid_ ___.. (Complete in Duplicate) may. 0 Date Issued ------ --- ------- Applicaa-ion is hereby made to the San Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. I. JOB ADDRESS AN LOCATION______ "3 DO },�/ -t-u .. om--------------------------- -----------•--•- -----------------------•--••---- ------- Owner I s •----•Owner's Name_.. Ayk ----- --•----- --------------------------------------------------- ------------------ Phone--,1QA----4-- ---_A.G.2, Address------------ ----•--- ----- - ' , ,. - -Contractor's Name--- 1�-- -- ------------------------------ •----------- Phone---ZY�.--� -9��7 ' Installation will serve: Residence Apartment House 0 Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __)____ Number of bedrooms __--Number of baths _`____ Lot size ----kp-----tm_{ Water Supply: Public system [ Community system ❑ Private ❑ Depth to Water Tabhe ________ ft. i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [a Hardpan ❑ Previous Application Made: Yes ❑ No 50 New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: T I (No septic-fankw cesspool permitted if public sewer is available within 200 feet.) Septic Tank. is anc ram nearest wel!_________________Distance from foundation-------------------Material------------.-_.__._____--____________-_______-. ❑ No. of compartments------.--------------------Size---------------------------------Liquid depth--------------------------Ca act Disposal Field- 985tfrom nearest well-----------------Distance from foundation--------------------Distance to nearest lot line------_______... ¢ ❑ umbe 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_____-.'______Distance from foundation__.... -------- to nearest lot line __. __.____ Number of its___ f___ -Linin material__C _6_AA_4 ri __4: Diameter_ ___Depth-----2.-f----------------- Cesspool: Distance from nearest well--------------"_Distance from foundation-------------------Lining material-------------------------------------- 0 Size: Diameter-------------------------- ------- ---Depth-----------------------------------------------------Liquid Capacity---- ---------------------9als. Privy: Distance from nearest well---------------------------'-----------------------Distance from nearest building------------------------------------------- ❑ Distance to nearest lot'line---------------------------------------------- --•- ----------------- --------------------------------- ------------------------------------ Remodeling and/or repairing (describe)------------------------- -----------------------•----•- ----------------------------•------- -----------•------•---------•--------------------------- t -------------------•---•----------- ---------------•-•----------- ...--------- --------------------------•--------•---------------------•------- 4 - 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) sem' ` --------------------------- (Owner and/or Contractor) By:----- -.. �------' Title f ` ( , )---- . - ------- --- --------------- (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...... ------------------- REVIEWED BY -------------------------- ----- • - ------- DATE---- --- BUILDING PERMIT ISSUED ------ ---------------------- DATE----------- •--- ---------- Alterations and/or recommendations:_________________ __ -- �� - _ ------------ ------------------------------------------------:-------------------7------------------------------------- -- --------------------------------------------------------------------- -•------------------•--------------------- -- ---------------------------- ------------------ -------- ---- - FINAL fNSPECTION BY:---' ---------------------- Date._------------------------------ SAN `. J 5SAN 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