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APPLICATION FOR SANITATION PERMIT Permit NO. . ,.1. ....�.. 0 A0 - _ - r�_. . - _. (Complete in Duplicate) ! I, Date Issued .__ 77/1.) �-- ., 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. JOB ADDRESS AND LOCATION------ 4_- --/-�----- -•-• ---- Owner's Name..------- !J''Q'" ° T= '''"`' r ='I--•-- PlSone Address 4` — --- ------ --- ------ Contractor's Name------ H' ---•------ ------ ----------- Contractor's -------------------------------------------- PJe-_!�-.�.. . Installation will serve: Residence Wl-"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel-E) Other ❑ Number of living units: Number of bedrooms _ __ Number of baths J--- Lot size __*� .� vlQ ____________________________ Wa+er Supply: 'Public isystem.'2__Community system ❑ Private ❑ Depth to Water Table --yer ft._. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Lo m El Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ❑ No New Construction: Y s No [ sr'7 L.�iPiC�7 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fank'or-cesspool permitted if public sewer is available within 200 feet.) Septic T nk:` Distance from nearest well_________________Distance from foundation--------------------Material______._____._________-----_...__________--__.- ❑ No, of compartments----- ------- ---------=Size-------------------------------Liquid depth----------------- --------Capacity---------------------- Disposal Field: Distance from nearest well---.-----------._Distance from foundation--------------------Distance to-nearest lot line------ Number of lines------------------------------- ---Length of each line-------------------------------------Width of trench----------------------------------- Type of filter material_________________________De Depth of filter material__°.___________-____ d Yp P �---Total length---------------•---.....------------------ 5eepa Pit: . Distance to nearest w 11 ---------T___.__.__Distance fro foun ation____ _ ______.Distance to nearest lot line__,__>l-- .___ } Number of its.__.___ .-_________Linin matenaLCC:.- Size: Diameter__-- ' 6 P 9 3-3.-------..Depth--- -------------------- . 1 Cesspool• Distance from nearest well------------------Distance from foundation--------------------Lining material-----------------------_-___________- ❑ Size: Marneter----------- - - ----------Depth-------------------------------- ------------------Liquid Capacity---------------------------gals. Privy:s Distance from nearest well....--------------------------------------------Distance from nearest building----------------------...__ ❑ Distance to nearest lot line________________________ __ f . . Remodeling and/or repairing (describe)________________________ 1 y° ---------------------------------------------------------------------------------------------------------------------------------------------------------------------- --- ----------'------------------- - --•-----------------.---------------------•--•----------------•----.._.._-------•-•---•........-•-•-------------------------------•---------••--------- ---------- - ----- -- r I , I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State pl ` and rules and regul tions of the San Joaquin Local Health District. 1 � * y !.------ - ----- --- - ---a_ - and/or(Signed', r� _ / Contractor) ! By:------------- ----------------------------- -- ------------- ---------------------------------------------{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 t APPLICATION ACCEPTED BY- DATE'______-•--#--------------------------------------- -- --------------------------------------- ----------------------------------------- REVIEWED BY----------------------------- . ----------------------------- -----• DATE-- ----------------------------------- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE.-------�-------._....--------------------------------- Alterations and/or:recommendations:---'---------------------------------------------------------------------------------- ------------------.... i _...------•-------------•-----------•---------------------------------------------------------------------------------------•-- ------•-- ---------••-------------------•--•------------ t - FINAL INSPECTION-,BY::------------- Date {= SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stotkton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised W-2100