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•T APPLICATION FOR SANITATION PERMIT Permit No. +ld__-(?'---'l I j (Complete in Duplicate) -x,� � , Vdillfall ate Issued ___��Application is hereby made to the San Joaquin.Local Health District for a permit t constr t the work herein descri ed. This application is made in compliance with County O •nance N . 549. - -- - - ----------- --------------------------------------------------------------- -- JOB ADDRESS '� LC ATION___-__ `6 Owner's Name = `" - - - ----------------------------------------- Phone --------------- - „r � r Address = ._ .1 ------------------- ---- -------------------------------------- ---------- ------------•--------------,------ - - Contractor's Name------ ------- ------- ----------------------------- ----------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Comm -i I ❑ Trailer Court F Motel ❑ Other ❑ r • Number of living units: __J-___ Number of bedrooms IQ_ Number f ' ths -_'____ Lot size ____ .]�"_� ,_ Water Supply: Public system ❑ Community system ❑ Private Depthalfoo'\�&ter Table ________ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Foam Clay Loam ❑ Clay ❑ Adobe /ardpan ❑ Previous-Application Made: Yes ❑ N,= New Construction: Yes? ", ❑ �, . TYPE OF INSTALLATION AND SPECIFICATIONS: [ ,, (No septic tank or cesspool permitfecl if-public sfwer is available within 200.feet.) W Septic ank: Distance from nearest well-e-- -Dist e fr foun anion----- __+Maferi I _____ ___ _____ ____ __ ___ �__ _. ILA I ___ No. of compartments-_- _ __Size?-_ __ __Liquid deptfh__ ___F'(""______-__Capaaty______ _ . Dispos Field: Distance from nearest well- o__ nj ! --- _-Distance to nearest I e Distance fro .ouridation__._____ Number of lines----- -- - - �ength of each line------- --Width of trench t Type of filter material epth of filter material____.__ --------- length------ ______- �e e it:- Distance of nearest well----�inin�---mDat raalCe.f�-�r� _Size Diameter___ Distance to nearest lot line r----------------- Number �--i__L___ p ! g p Cesspool: Distance from nearest well-----------------Distance from foundation_-------------------Lining material____________--,_-----_ .---- ❑ Size.:_Diameter--- ------ :: -Depth _---------------- -- -----Liquid Capacity gals. -s __....—r;- .r . Privy: Distance from nearest well_________ _______________________ ------Distance from nearest building_________________________________,_._____. ❑ Distance to nearest lot line- -------- ----------------------------------------------------------------------------- ------------ - Remodeling and/or repairing (describe):---------7 --------. - - ----- --------- -T ¢-------------- _!_..—� ' --------- a-.,:- �--------- c..�` - �� ------ --- �.: ' '''�-�- ` -�— ,�,..�lt ------------ '--- --------_----- =3 -- 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, i (Signed) _t:.� ----=- --- I- --�------------------------ - (Owner and/or Contractor) R r (Title)------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----<- ----------------- ------------------------------------------------------------------------- DATE--J REVIEWED BY----------------------------------- -------------- DATE BUILDING PERMIT ISSUED---------------- - DATE---------- ------------------------------------ Alterations and/or recommendations:l----------------------- = -------------- A--- -------------------- --------------------------/1----------- - � �- __.._� -----------------------_--:a.. '----------- - --+ J-^-� -------'----------------------- -----`*`------ -. --- -- Ir. --- --- ---'---- ----------------- '- - -------___ ---_---�--- ----------- ----------------------- --------- ------ i = - ---- .. FINAL INSPECTION BY:----- _;e --------------------------- ------------- Date_. ------------ -------------- --- ----•------------------------ SAN JOAQEIIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Stree4 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California —t ES-9-2M 8.51 Revised W-2100 ,