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APPLICATION FOR SANITATION PERMIT Permit N:dy' . (Complete in Duplicate) Date Issu7._S.� Applica-%n is ereby 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------.. -- -----------------�s�` Owner's Name-----11A.-wW.Wt .....aC.�m.4.t --t--------•---------------- ------------------------•-----------------------. Phone._-!V-4"7;?--- Address------------ Contractor's Name------- --------------------------------------- Phone.,-1.q.0 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: J____ Number of bedrooms ._ .. Number of baths J-_- Lot size -----4!;�:'X.,l A �___._.......................... Water Supply: Public system Ercommupity system ❑ Private ❑ Depth to Water Table y17 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0--Hardpan ❑ Previous Application Made: Yes ❑ No Pr New Construction: Yes Rr-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 we117!!TDistance from foundation -Z0�...••...Material_ Ce-C.--- gr-- No. of compartments_ a2_-_:__-.--._Size.,`s6...1CS�d__.___---Liquid depth-___�y ----_______Capacity...R4-d--- _._. DisposaField: Distance from nearest well.-71tl` ...Distance from foundation.....`ot.0......_.Distance to nearest lot line-_5......_.... Lr1 Number of lines----------�---------------------Length of each line-----/D_Q'.............Width of trench-----,�y.��.._._......._..___ r Type of filter material-;F-F- -�ct�_____Depth of filter material___--�*------------Total length........Z4'.A__________________------ Qi Seepage it: Distance to nearest wel0`h%. ---------Distance from foundation_..3'a...._._.Distance to nearest lot line_...'s...._.. w .. Number of pits___ l--------------Lining material./.X,Y..�4.5*-Size Diameter-----! ------------.Depth Alp........ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material--------------------- ---------- ❑ Size: Diameter--------------------------------------Depth-------------------------------------------........Liquid Capacity------------ -------gals. w Privy: Distance from nearest well-------------------------------------------------Distance from,nearest building------..__.__--------_.................... ❑ Distance to nearest lot line--------------------------------------------------------- •------- (10 Remodeling and/or repairing (describe):----------------------------------------------------------------------- --------------•---------•------------------•••---•-------•----•---....... -----------------•••-•---••---•-••.•••-••----------------•----••-•---------•-------•-•-•-•-----•-----•----•-•---•-••---------•------•----••-•-----•------•---•----------••-------- •----•-------------------•----------- -------------......................................................------—------------•----•----•------•-----------------........------------•------------------------------------------••- •----------•------•---- 'Lr► ---------•-----------------•--•-------------------..........................................................................--..................................................................................------------ 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)......... ------------------------------------------ ---------- (Ow and/or Contractor) By:..................................... ..... - ---------------------------------(Tifle).. .._.� (Plot plan, showing size of lot, location of system in relati to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.... - 1 DATE---- Z7 REVIEWEDBY----------------------------------------------------------- ............................. DATE.......................................................... BUILDINGPERMIT ISSUED.........................................................................................--........... DATE......................-------------------------- Alterationsand/or recommendations----------- ------------------------------------"-----------------------.....-------------------•--•----•------------------•----•--------.....-•--•-•-----. ------------------------------------------I...........L........ ---------ZI—t-1......... -------------------F -------- -V- ------------- ......................................... ----------•--------------------•--------------------------------•----------•---------------- •---••---------------------.--------•-----.----•-.-----...---------.....------------------.---• ----------------------------•-•.. ----------------------------------------------- ------------------------------------------ ..--....------------.-----------.----------------•-------------.------------..--.--....---......----••............•••. ----•- 1 - �- s FINAL INSPECTION BY-----------------------------�--------�-� �`'n--- Date--••----------------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 Revised W-2100