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APPLICATION FOR SANITATION PERMIT Permit No. . - l. ........... t i (Complete in Duplicate) Date Issued Application is hereb ade 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- g- --------S© `-� �F -L=-----------------•------------------/--------------------------= Owner's Name l� Phone Address - ----- -------•------------ - - -- - - Contractor's Name--- M��' t - a §' 'R ------------------ Phone-------------------- �" -. i;, --------------------- ------------ Installation will serve: Residence Apartment Hous Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units:,-/----- Number of bedroo _-- Number of baths -_1_-_ Lot size -._--_---- ` ----------------------------------------- Water X- - _ _____________________ Water Supply: Public system ❑ Lmmunity system-❑°-�-Private-"'- Dept hr,+o Water:,Table ........ ft. Character of soil to a depth of 3 feet: Sand ❑ Gr vel ❑ Sandy Loam ❑ Clay Loam❑ Clay ❑ Adobe� Hardpan ❑ Previous Application Made: Yes ❑� No �9New Construction: Yes, .] No, ED TYPE OF INSTALLATION AND SP}ECIFICATIONS:1 { (No septic tank or cbsspool permitted if public sewer hs available within 20 feet.) Septic Tank: Distance from dearest well--,,1�aq-_-__•Dishanf,—,m K u d +,a on_`fl _.r___..Materia___4_v_` � No.lof corrpar�tmenu--------------------------Srze--------------�----�-- Liquid:..de�th----------� �------Capacity------------Q-�--- W �� I Disorpas I Field: Distance from :nearest well_.__._....._.___Distanc'e'-from foundation,._,�Q ___._.Distance to nearest lot line-------J'�...____. Typ�ber oz lines-------------�____-- ---- """ Length of'eachliine_______-----?- ---- Width of tre?nch----------- sal ! . Num of filter material De th o filter material________jf�_�f______.Total len thi_______ __ ry -N p 1, ,... _ 9 I --:--1. ---- r i t) Size: Diameter-__. nearest lot line-______�f Seepage Pit: ------- Number of pts to rest well-----� Lining material �founds to n_________ _.._.___:Distance to Depth________________________________ Cesspool: Distance from nearest well________________bis+ante from`fundation--------------------Lining mateial____--._-_----.---------------.------:. ❑ Size: Diameter------°.--------- "- Depth t ----------------- -----------------Liquid Capac ify----------------------------gals. Privy: Dista nce from nearest well___.____________________---------___--------------Distance from nearest 6uildinq}__-..-----.-..----.____--_____.__-__-_ Q ❑ Distance to nearest lot line------------------------------------------------•-----------------•-------------------------------------------------------------------------- I m Rem g and ar r . airing (describe}; ------- ----------- - -.r -`- --- ----- --------------------------- A.-___----.1-------------------- --- ---- _ ___________ _ .--.yP�___ _ _______ ___ __ _ __� _-____ L - `uly ;- - - -------••--------- L------ I hereby certify t I have prepared this application and that t e work will done in ccordance with San aquin Couny ordinances, State laws, and rules and regulation of the San Joaquin Local Health District. , (Signed)- -{-a-Y. - !.! c.5 ------ Tom' !----------------------------------------------------------------(Owner and/or Contractor) B :. .... �` ___-- --- ------- ------------------------------------------------(Title)-------------------------#------ ----- -- ------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ------ Q------------ ---------------------------------------- DATE---------- - --{ -- REVIEWEDBY-------------------------------------- - ----- ------ ------ DATE-----------------------------------••---------------------- BUILDING PERMIT ISS J1 D = ------ DATE------------------------------------------------------------- Alterations and/or recommendations: ----=------------------------------------------------------------- --- •--•--------------- j--.----------------------- ---------- i (---/--- FINAL INSPECTION BY:..--•- -•------------------------------------------ Date------------ -/-----d: -- --------------- 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 I0•52 Revised W-2100 f