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IIII ; APPLICATION FOR SANITATION PERMIT Permit No. .__q,. 7..`_ (Complete in Duplicate) Date Issued ___/7(. ; 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. 'D ^ �-{ w i45 �.11 � T1�� JOB ADDRESS AND LOCATION__ / iLG _ 4� /� ` � ' --------------- --------------- Phone- ---- Owner's Name_ �tC ---------161-SV Address � c-- ��. _ �/_Y7.L.�� J ContractorsName------------- �� `�_[5 .e----------------------------------------------•----------------------- Phone , Installation will serve: Residence % Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __I---_ Number of bedrooms -3-. Number of baths f___ Lot size ___40 h /,,,- ------------------------ Water Supply: Public system 19 Community system ❑ Private ❑ Depth to Water Table.20ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ ! Previous Application Made: Yes ❑ No R New Construction: Yes ❑ Noj TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank"or cesspool permitted' if public sewer is'availabie within 200 feet.) ' 'r v Septic Tank: Distance from nearest well Distance #rom foundation_____t Septic No. of compartments_- ------------------Size�$.�" ' ��_b_.Liquid depth---S—Z!-----------Capacity'rS v)j Disposal Field: Distance from nearest welle�-Yl�aa,�Distance from foundation---]'a----------Distance to nearest lot line.`_'____-_. Number of lines.--�--y Length of each line-__ .Width of trench.__ __- --- �-1�''------ ��j►� � ------------ -------- ___S.,of filter material/_�__&A_ '/.--Depth of filter material_____ __ _a_-_____._Total length 2_U_____________________________ ` �0�__._..Distance to nearest lot line_- - Seepage Pit: Distance to nearest well4 __Distance from foundation__ ___ _. Number of pits._d_p k_..__.___Lining mateSize: Diameter�t- --------._.Depth-_ �_______--------------- !� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________--_-____._______________. -- Size: Diameter--------------------_._--------Dep-th.,,_._y_....... ------ Liquid.-Capacity- ----------------"_7---gals.p Privy: Distance from nearest well---- --------------------------------------------Distance from nearest building.----------------------------------------- 11 Distance to nearest lot line---------- -----------------------------------------------------------------=-------------------------------------:------------------------- Remodeling and/or repairing (describe):-- - --------- -- --- -------------------------------- •- -------------•--•-----------------------------•------------------------------------ -• --- - - -------•--- - -- ---- -- ------------------------------ ---------------------------------=-------- •------------------ ----------------------------------------•-------------------- -------------- a I hereby cerfifyAaf 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State 6wsland rules and gulations of the San Joaquin Local Health District. -f� c x (Signed)----------------- ----�..- - _ `------------- ------(O�ner nd/or Contractor) �. -By:_------------ ------` .�• (Title)_- - (Plot plan, showing size of lot, location of system in rel ti n to wells, buildings, etc., can be pl d on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------- --- -- ------------------------------------••-------------------- DATE----- J' ./------------------ REVIEWEDBY--------------------------------------------- --------------------------------------------------------------- DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------- --------- DATE------ --------•----••--------------•-----------------•------ Alterationsand/or recommendations-------------------------- ---------------------------.---------------------------------•-------------------....-.---------------------------------------------- ----------------------- ------------ -----------------•--------------------------------------------------------------------------------------------------------------------- ------------------I----------------------- ------------------------ -------- ----- ------------------------ FINAL INSPECTION BY: .=�r ------------------ Date = - --------------------------- ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Sfreet Stockton, California Lodi, California Manteca, California Tracy, California /f