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r APPLICATION FOR SANITATION PERMIT Permit No. _6s 4►.. ... (Complete in Duplicate) Date Issu 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...... --------------------- I. --------------------------- Owner's Name. / Y!?-ati�• -- ----- ` �� Phone.. .y; / Address-----------�-7K..-(f} .... ass. ......------------------------------------•----------------------------------------•---------------------------------•--... Contractor's Name-------1 = --_-------•---•-------------------------------------------------------------------•------------ Phone. Installation will serve: Residence [H''Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms ._3._. Number of baths _1.... Lot size ____X .-,Xl v�________________________ Water Supply: Public system 0-Community system ❑ Private ❑ Depth to Water Tablp Jk ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Eg- Hardpan ❑ Previous Application Made: Yes ❑ No E&-j-'~New Construction: Yes [ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) /a • Septic T k: Distance from nearest well__�4kR-_Dista�`from fou;dation______ __________.Mate I�.___._..________..___________.._.__._..___. No. of compartments______a2._..___..___Size_____________X �_________Liquid depth...... _. Ile __-__---__Capacity.....T'_r 2 tl . s' Disposal Field: Distance from nearest well_.��..Distance from foundation____..............Distance to nearest lot line..__..__......... [� Number of lines.._.....�_______-----------------Length of each line____�_O0__--___----_-_-.Width of trench.._....�._I................... tJl Type of filter material..;c__nP_Ck___-Depth of filter material_-_--- --------Total length.....A A.*........................ 0 Seepage Pit Distance to nearestwell_ ._Dista a from fo ion.._3o ..DD?�istance to nearest lot line Number of pits-------1-----------Lining mate ialA1Y0._RR_C* e: Diameter-__-7 1"._____._Depth----- ................... Cesspool: Distance from nearest well___-_-_-_---.-__Dis nce from ndation-------------------- material------------------------------------. ❑ Size: Diameter--------------------------------------Depth ------------------------------Liquid Capacity---- ....................gals. i Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ r_1 Distance to nearest lot line------------------------------------------------------------------------------------------------------------------------•-------------------- Remodeling and/or repairing (describe):......................................................................................................................................................... b -•-•-----------•----•-•----._...-•-------------------------------------•---•------•---------•-------•------------•--------•-----------•-----------------...---••------------------•...................................... --------------------------------------•• •-------------------•---•--------•-----------------------------------------------------------------------•----------------•-------------------------------•------------------------- 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) '----------------- -- -_.------D--�-------------------- ... -- ( ner and/or Contractor) By---------------------------------------------------- '�'LJ ��"--u!----- ��.i!. lTitlel `'" ------------ (Plot plan, showing size of lot, location of system in relation to w s, buildings, etc., can be placed on reverse side). FOR R,, ,DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- -- --- �i�.l. •--------.._ DATE__`1 2-,? j�� -- ---------------- REVIEWEDBY-------------------------------- -------------- DATE ..................................................... BUILDINGPERMIT ISSUED..............................................................- ..................................... DATE------------------------------------------------------------ Alterations and/or recommendations------------------------------ -------------- -----•----•-----------------------•----------------•----•---••-------------.....-----•--•-•--•......-•---- -- .--•..........................--------------------•-••-•......-------•-----•----. rii ----------•------------ -----------` -�--•--- ---�---- ------------------------- ------------------------ --------------------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- /�, y _)-,.p FINAL INSPECTION BY----------------- .j-Y�'►----- ----------- Date---•---------------........ .---5----------------------------------------• 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