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t 7 APPLICATION FOR SANITATION PERMIT Permit No.�;,3 .0__7_____ (Complete in Duplicate) ,— /).., Date Issued ��__y/.73 Application is hereby a to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is mad�,_i3,compliance with County Ordinance No. 549. JOB ADDRESS AND LO ATIO ---------- Owner's Name------------------- a k------ - - ---- ------------------------------ Phone.----------------------------- -- � r Address........................ ----- ,� Contractor's Name---------- -- -c�_ ••-•_- -� _ _ K__------------------ d ' 1 _ , afr"G '_- Phone �� Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 3 Number of living units: ________ t er of bedrooms ___1_ Number of baths --- size - -----d-------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ravel E] Sandy El Loay Loam El Clay ❑ Adobe Hardpan E] Previous Application Made: Yes ❑ No New Construction: Yes o ❑ w I 4 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public er is available within 200 feet.) Septic T Distance from nearest welYd_zD+stance from foundation_ ()--------------Material ______.___ ____. No. of compartments �---------------- Size----X1,0-A�------Liquid depth----- -------Capacity.... --�. ---- -- I Disposal F' Id: Distance from nearest wellIA Distance from foundation or. __l_8_______._.Distance to nearest lot line__ ....._... 11 .11 Number of lines__eY - G --- Den9hhofffiltehmline ateria ,f_ �f ___.=otalWidth lenf th n� ?:- Type os filter material ____ p g Seepage Pit: Distance to nearest well__________________Distance from foundation--_----..__-__-___.Distance to nearest lot line----__._____.___. ❑ Number of pits------ ------Lining material........---------------Size: Diameter__---------------------Depth-------------------------------. Cesspool: Distance from nearest well-----------------Distance from foundation__-_____--- --_,- -Lining material_______.___________-_________.__..__. Size: Diameter-------------------- -------------Depth_------------------------ --.--'-----Liquid Ca acit ------- als. Privy: Distance from nearest well____________________________---------------------Distance from nearest building------------------------------.--_....._. ❑ Distance to nearest:lot line---------------- = ------------------- ---------- ----------- r Remodeling and/or repairing [describe):___.-p-- 'i.aI- - --- --. ------ ----------- .-- �x- ----- -- 1_._. --lr - 1�--- _ ` -----------( ___________ ------.. I' . ._r te ,`-i ---------------------------------------------------------- f!t f r ------------------------------------ --------------------------------- -•----------•----•---------.._..--------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law and rules and regulations of the San Joaquin Local Health District. {Signed-------" l�' " f!I -!`�' •r1✓�rt ` � '�- .�!/��( ------------------- Z,13 �and/ r Contractor) I k By:----- ,--1-------- ----- --------------------------------------------------------------------------(Title)----- C ----------- ------ (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 I BUILDING PERMIT ISSUED----------- � -----------------------------•--------------------------------------- DATE--------- ----------------- Alterations and/or recommendations------------------------------------------------------------------------------------ -----------•-------------------------------------------------•------------- ---•---•-•- ---------------------------------------------------------------------------------------------------------------------------------------------------•----------------------•----•--------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------•-•-----•-•--------------- i ----------------------I----------------------- ------- ------ ------ ---------------------- -------------------- ------------------------------------------------------ ------------------------------- FINAL INSPECTION BY:.. Date . �� --�- -------- l 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 e ES-9-2M 10-52 Revised W-2100