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APPLICATION FOR SANITATION PERMIT Permit No. __...................... (Complete in Duplicate) 3+ s Date Issued'----�------- Application is hereby made to the Sa Joaquin Local Health District fora 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----ci9ow a_�41�: lAX e_ DR -. C_1 "__-IG=-r40------- ------ ----- --------- -----_ Owner'sy--_---- Phone- ----- Address--------------------o. Vie----------------------------- ---------- -- - -------------------------------------------------- --------- ----:-----•--------- --------- 77 Contractor's ------------- ----------------------------------- Phone--F�--her-*-- Installation will serve: Residence [i�Apartment House ❑ Commercial ❑ Trailer-Court ❑ ,Motel ❑ Other ❑ Number of living units: .;/___ Number of bedrooms __i_ Number of baths _,/_____ Lot size ____j/M_`,,X.*2u ----------------_________ Water Supply: Public system [JY Community system 0 Private ❑ Depth to Water Table ......-_ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam E] Clay Loam F-1Clay ❑ Adobe rdpan E]Previous Application Made: Yes E] 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 well---_____________Distance from foundation __________________Material__ No. of compartments-------------------------Size--------------------------------Liquid depth-----------.____.__________Capacity-----------_------_-- Disposal _--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_ Depth of filter material-----------------------Total l_en t.h____... __.._ e___Seepage Pit: Distance to nearest wl_ 2tv0-._:-_Distance from foundation--...12 Distance to nearest tot lme _ � y___Depth_______2Dt-............... Number of pits------_1------------Lining material.Z$iS.�__Size: Diameter__.__ _._ Cesspool: Distance from nearest welL_---------------Distance from foundation-------------_......Lining material...................................... ❑ Size: Diameter-- ------Depth-_--------------------------• ----------------Liquid -Capacity............................gals. Privy: Distance from nearest well---------------------_-__________________________Distance from nearest building............................._............ ❑- Distance to nearest lot line. -------------------------------- ----- ----- ----- Q Remodeling and/or. repairing (describe)._______..__�iW i"' -h_�_ _!M11 1EtJtl� _. _F� t4.lNt_4! .Ca' .y'1f' T4OX-------------------------------------___-----.------------------------------------ ---....---------.....--- 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. t Owner and Contractor (Signed)-----..-��-- +- f ` --�-'�J�a�. �-��i--•------------ -- ----------------�-..•(�.� � ) By:......... -------------------------------------------- - --------(Title)-----4 0 (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 ----- ------- ------- - BUILDINGPERMIT ISSUED------------------ -------------------------------------------------------------------------------- DATE__ - Alterations and/or recommendations----- ---- - -------------------------------------------------------- ---------------------- -------- --- ------------- ------------------------------------------------------------------------------ - IX FINAL INSPECTION BY: --------------------------------- Date- ----- ''y ----r--- - --------- 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 8-S1 Revised W-2100