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f � APPLICATION FOR SANITATION PERMIT Permit No. r1� 4 (Complete in Duplicate) �1 �� Date Issued -- Application 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 Or inance No. 549. ' GG JOB ADDRESS AND LOCATION-------- --- ----l----- --------s--- L,c. L� ------- ---------------------------------------------- Owner's ---------------------------Owner's Name-------------------------------- Ys2i., ,------ - ---- --------------------------------------- Phone / Address------...... -------------- — l -----------•--------------•--- -------------- Contractor's Name_-------------------- ----- Installation - - i y Phone ��'6 4-�f Installation will serve: Residence � Apartment House ❑ Commercial ❑ +Trailer Court................. ❑ Motel ❑ Other ❑ Number of living units: -/---- Number of bedrooms -- Number of baths 1-/--- Lot size ----_--- Water Supply: Public system Community system # E ,� y y ❑ Private ❑ Depth to 4- Table �ft. Character of soil to a depth of 3 feet: Sand ❑ 'Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [] Adobe Hardpan ❑ F Previous Application Made: Yes ❑ No 5- New Construction: Yes ❑ No qr -- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if,,public sewer is available within 200 feet.) Septic Tank: _ Distance from nearest well lTG Distant from 4oundation- -i.. .Material ----- No. of coin artments..__1 �� -•� �r ----------- --------- ---------- i p --- -----Size Liquid depth �r� ---------Capacity_c-05: Disposal Field: Distance from nearest well------------------Distance from foundation--_-.-------_---.-.Distance to nearest lot line_- U = ❑ 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-.w_ ---__Distance fro foundation__�Q_-'�..-..-.Die+ante to nearest lot line-.-/0_.I t Number of its.---L-_ ._ --Linin E }--.Size: Diameter_-�0..--------.Depth_--ate,_--____-_ p g material- .i Cesspool: Distance from nearest well-------------- -Distance from foundation--- -------------- Lining material------_---.--.---- .----_---.__ ❑ Size: Diameter----------------------- ------------ -Depth---- �-------------------------=*---------------Liquid Capacity----------------- i Privy: Distance from nearest well---------- ____ ________________ _Distance from nearest building ) ----------5als. ❑ Distance to nearest lot line_---- _-_-'.-___--"'-"_� ;.----------------------------- --------------------------------- --- ----------------------------------- Remodeling and/or repairing (describe):-------------- ------------••-------------•------ - " t ----------------------------- ----------------•--------------•------------------ ------------------------------------------ #{ -----------------•--------•----...-----------------------------------------------••--.-••-•----------'.-•---------------•--------••------••-----•----------_------------------------------------------------------------- I hereby c that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S+ate laws, and rules and regulations of the San Joaquin Local Health District. ' (Signed)., - -�' r ----- -f - or Contractor) Plot Ian, showing size of lot, location of system in rella�*ontow�,'building, etc., can{bel pla� onreer eside, ey- { p g � } R D TMENT.USE ONLY APPLICATION ACCEPTED BY-------- -- ---�-. _- _- - • DATE--------L. REVIEWED BY-------------------------------- DATE--- -- - -----------•------------ BUlLDING PERMIT ISSUED----------------------- DATE ---------------------- ----------------------------------------------------------------- ..- ---- A terations and/or recommendations-------------------------------------------------------- 77---------.-_ _ ----------------- FINAL INSPECTION' BY: ---- ------- Date-------- -- ---- 3 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-4-2M 10-52 Revised W-2100