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\� APPLICATION FOR SANITATION PERMIT Permit NoV.- I (Complete in Duplicate) /Date Issuef3__ 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-------�/-----•- "...............f��-t_ _a 1.-----------------•----- Owner's Name------ 'Yi'Z ..... Address--------o2_7l°;:---d --- - .,}..------- Contractor's Name_______ � Installation will serve: Residence ®/Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _a___ Nu ber of bedrooms _k3__ Number of baths _J___ Lot size ____dz S� `_/A- _�_•-_--:••_--•_-•__- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table _�i.V. ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe El Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 2--Ko ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Ta Distance from nearestwell-.'e.72 Distance zfrom foundation.../A !.......Material.__C..e ____ y _._____._. � y____No. of compartments-.___-�__________.__Sie_S 'y4 . ----- Capacit .___�__.� ___i4A_____ Disposal Id: Distance from nearest well_�B�-c Distance from foundation-----A ..........Distance to nearest lot line.......... Number of lines--------- -----------------------Length of each line..... ---------Width of trench.._____ _-................... Type of filter material__S[_%P*--____-Depth of filter material---//_____ Total length-------1a�_'___.___.__._ �' Seepage _______________ Distance to nearest well__ _____Distance from foundation__:_3Q_0' __..__..Distance to nearest lot line ___S. __ 21, Number of pits__.,______---____Lining material X$_o"_ Size: Diameter__-.�,g----------Depth------- ________________ 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--------------------------- Remodeling and/or repairing (describe)________________________________________________________________ _ ---------------------------------•-•----------------------------------------------------------------------•-•-------------------------------------------•------------------------------------------------------------------- ---------------------------•---------------------------------------------------:------------------------------••-------------•--------------------------------------------------------------•-------•------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------- 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)---- -------------------------------'Qr--------------------------------------------- ----( ner and/or Contractor) By:_...... -(-----e 2----1"-�- _(Title)_ fit,/ - - (Plot plan, showing size of lot, location of system in relation to w , buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- U)_-- =- 1, DATE . . ------ REVIEWEDBY --------- -------------------------------------------------------------=-• DATE---------_---- BUILDING PERMIT.ISSUED------------------------- ---------------------------------- ---------------------------------------- DATE Alterations and/or recommendations:--------------------------------------------- --•-----:--_--------------- -•---•-------------------•-- : __ : = -- - ' .4 ..----------- ---- .... �, 6 - ��, s- FINAL INSPECTION BY:.................{.�..- �U'�l-l-C't ------•------ Date.............. ---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sheet 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 - �