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J �✓ � APPLICATION FOR SANITATION --� Permit N �p � � ON P�RM6T o. ------- --ll_._Q--.". (Complete in Duplicate) Date Issued _ ______--__ Y-- ApplicaTion is hereby made to the San Joaquin Local Health District for ermit to cl9rfstr nd install the work!� Lqt e herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION______ Owner's Name_ 171S� t_c � /_- - ---------------- Phone-----1--f--- - ---- ------ - - Address------- Contractor's Name------ -��-s1 Phone-44 ------•. Installation will serve: Residence Apartment�House ❑ Commercial ❑—Trailerb-Court ❑ Motel ❑ Other ❑ Number of living units: I___ Number of bedrooms _3___ Number of baths Lot size _____ Water Supply: Public system RT" Community system ❑Private ❑ Depth to Water Table*_ �Dft. Character of soil to a depth of 3 feet: Sand ❑ #Gravel ❑ Sandy Loam ❑ Clay}Loam ❑ Clay ❑ Adobe a-'Hardpan ❑ Previous Application Made: Yes ❑ No Er"'iNew Construction: Yes 2�.No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 4 (No septic tank or cesspool permitted if public sewer is available within•200-feet.) Septic Tank: Distance from nearest well_-��C sfance�from�foundation-1A?_et_.Ma�erial_,_(�. crit --_.-_-- No. of cornpartments.-----�---------------size �•a�--t.P---x_kl----Liquid depth---4__!_7--------------Capacity-_-F00- y Dispos Field: Distance from nearest we'll .T�.cQ�-Distance from foundation_-i0-_-______.__Distance to nearest lot line.-S______-___ Number of lines-----= =------ �!-------------Length of each line---? __`-'-:'_ Width of trench--,;A-#--------------------,...... Type of filter material_ */i0r_�/__Depth of filter material er_ _________Total length__.__2_S:__.---------------------- Distance o nearest wel �__�A.,0f9-Distance from•foundation1_�_ _. Disfce to nearest lot € an ;e_,.,�_. -___-___ __ ; Seepa e Pit: Number 'f pits--------7"._ _ ;Lining mafieria&7� Sze: Diameter 6 Depth_e�?_ ,----- 1 , Cesspool: Distance from nearest well___:________.___Distance from foundation___________________ Lining material---------------.--------------------- Y ❑ Size. Diam::eter------------ -------- ------- -------Depth--------------------------------------------------_-.Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------------------.---------------------_,_-,Distance from,,nearest building----------------------------------------- El _____-___ __________-__________--_____❑ DistanceJo nearest lot line.--------------------------------- _:w - ^,,,, - - Y i Remodeling and/or repairing'.(describe):- --------------=---------------------------- -------------------------------------•-------------- . ----------------------------------------- ------------------------- ------------------------------------------- II Ihereby 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. ed ,p (Sign ) -�-�--� - r "" C .eS� c .�z ----- ----------------------------- (Owner and/or Contractor) By:--------- r-�„ , ----------------------------------------------------------------------(Title) (Plot plan, showing size of lot,`locion of system in relation to wells, buildings, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTEDt.----.-__-_ DATE Z l =---------- - - '--------------------- REVIEWEDBY-------------------------'------------------- --- ---------- --------- ----------------- --------------------------- DATE--------------- BUILDINGPERMIT ISSUED---=----------------------------------------------------------•------------------------- ------------ DATE.----- ----------------------------------------------------- Alterations and/or recommendations:------------- ------------ -----------------------------------------------------------_----..---------- ----------------- ----------I-------------------------------------------------------•---------------------------------------------------------- ------------------------------------------------------------------------------------------- -------------------------- ------------------- - ---------------------------------------------- ---------------•- FINAL INSPECTION BY:................ . ----------------------------------------------.�------------------- Date.-------------------- ---J f = 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 a ES-9-2M' ' Revised W-2100