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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued --- Applicakion is hereby made to the San Joaquin Local Health District for a permit to consfruqt and install the work herein described. This application is made in compliance with County Ordinance No. 549. 2-2-Z-020 C A- .. .......... JOB ADDRESS AND LOCATI -- - - r,-- ----- -- --- -- Phone-----1-1114!V-- ---- Owner's Name____. -__-_. - ne---- ---11/0------- -41- - -- --- - - --------- --------------------- ------4------------ v V. Address---------------------------------------- - - ----- ------1,64-11........./-Z/, ----------- /... ---------0..I;/---/Xa �-z - -------------------------- Contractor's Name---------•------------------------------------------------------------------ ------------------------------------------------------------------ Phone----------------------------------- Installation will serve: Residence R---Apartment House E] Commercial [] Trailer Court [] Motel [3 Other E] Number of living units: Y--- Number of bedrooms A7- Number of"baths Z-- Lot size -;!�---- - -- ____________________________ Water Supply: Public system El Community system [] Private 2'-'Depth to Water Table Character of soil to a depth of 3 feet: Sand [] Gravel El Sandy Loam R., Clay Loam E] Clay ❑ Adobe E] Hardpan E] Previous Application Made: Yes E] NoE�-�ew Construction: Yes TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if publy stwer is available within 200 feet.) X nearest well anW fro �ouinjAk�on-/49------- No. of compartments......Z ....Mat ripl-A ------ Sept c Tank: Distance from -0 -----------Dist ------------Size-S------------------?r ----Liquid Liquid depth----- ----------- -------Capacity---- ---------------- JR1 I e * — In Disposal Field: Distance from nearest well-MDiI stance from foundation-/&4--tw?P--,.eDistance to nearest lotll or -hjr�e- - "✓ ^"� ------ Number t lines-------- Length of each line------1610---------------Width of frenc ----- Type of filter material-S-U/6ALf-k-Depth of filter material ------Total length------- --------I------- Seepage Pit: Distance to nearest well----------------------Distance from foundation___________. Distance to nearest lot line_._____._________ ❑ ine----------------- 171 Number of pits----------------------Lining material--.--------------------Size: Diameter--- .......Depthi-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation____._._____._..... Lining material________.---__.____.____.____________. ("!,`� ❑ aterial---------------------------------- El Size: Diameter----- - -------- ------------------- Depth--------------------•-------------------------------Liquid Capacity----------------------------gats. L� Privy: Distance from nearest well---- - ---------------------------- -------------Distance from nearest building El -------------- -------------- -------------------------- r �011 Ir 'Distance to nearest lot line--------- ------- - -------------------: --------------------------------------------------------------------- Remodelingand/or repairing (describe):---------------------- ------------------------------------------------------------------------------------------------------------------------------- ---------------------------—.1---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------ ------------------------ -------------------- ---------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------- 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 no regulations of the San Joaquin Local Health District. (Signed)...../_ P -------------------- ----------------=--------(Owner and/or Contractor)iBy:------------------------------------------------------------------------------------------------------------------------------------(Tifle)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). jI-;G!7E)P R TENT USj-ONLY J APPLICATION ACCEPTED BY-- ---------�-- - DATE '—/ ---------------------- REVIEWEDBY-------------------------------- - -- ----------------------- --------------------------------------------------------------- DATE-------- --------------------------------------------------- BUILDINGPERMIT ISSUED---------------------------------- -----------------------------------------------------I-------------- DATE------------------------------------------------------------ Alterationsand/or recommendations:------- ---------------------- --- --- ----------------------- -------------------------------------- --------------------------------------------------------- --------------------------------------------------------------------I--------------------------------------------------------------------------------------------------------------------------------------------- ----------------- --------------------------------- - ------------------------------ -------- -----------------------------------------------------------I-----------------------------------------------------....-- ----------------------------- -------------------------------------------- ------------------ -------------------------------- -----------I------------------I--------------------------------------.--------------- ---------------------------•--------- ----------------------------------- ------------------------------------------------------—------------------------------------ ------------------------------------------------ FINAL INSPECTION BY------------ ---- -- ------ -----•._ _ Date........ ---------------------------------------------- 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 1n5446 T.... 1.-Sl