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u s APPLICATION FOR SANITATION PERMIT ermit No: in Du hcate Date Issued 1�.A ! (Complete p' I s. `67 -3 15' Application 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. ,55449, JOB ADDRESS AND LOCATION----------S�d - t- __C7 __ f I �u ----- Owner's Name• ---- _"_1C --------- - - -------- ------------------- -------------------------------------------- Phone---- ----------- -- Address---- /�,! Contractor's Name- ------� p _&`�'-------------------------------- -•------------------------------------ Phone- ----------- Installation ----------- Installation will serve: Residence X Apartment House ❑ 'Commercial ❑ Trailer Court ❑ Motels❑ Other ❑ �-- �- X- Number of living units: ___ Number of bedrooms ____---- Number of baths --- Lot size --- --- �---- - I---------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table y�_ ft. Character of sail to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ! Clay ❑ Adobe g[ Hardpan ❑ Previous Application Made: Yes ❑ No'tg New Construction: Yes M No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ! (No septic tank or cesspool permitted if public sewer is-available within 200 feet.) Septic Tank: Distance from nearest well N4 W _Distance from foundation-----A0` Material-. ,, Q _ No. of compartments___._. _.._______.__SizeS6_"1'`'�A__')C_b-______Liquid depth---- ------------ _-Capacity_ 00 Disposal Field: Distance-from nearest wefiV4__41__Distance from foundation___A_____._.._.Distance-to nearest lot line------ Number-Zi' ---Numbero{ lines___________ ____ ________________Length of each line----- ____ _Width of trench---!�---------- .__.______--- I Type of filter material_A__)?q!k -__Depth of filter material___2_!V_---------Total length______FI___Y __________________________ l Seepage Pit: Distance to Aeatest well VO.00-11_____Distance from foundation"_--1�?_/____-_.Distance to nearest'Iot line---/.�?_ ...... r ® Number of pits_______-1------------Lining material_ --__.Size: Diameter------;4............Depth_____ r----"________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______________________________________ ❑ ---------.._.Liquid Capacity---------------------------gals.Size: Diameter--------------------------- ----------Depth--------------------------------�,s r ------..Distance from nearest building------------------------------------------ ~ Privy: Distance from nearest well_____________________�______----___-__- � ❑ Distance to nearest lot line_____ __________________ �- 1 Remodelingand/or repairing (describe):--------------------------•----------------------------•---•---------------------------------- --------------------------------------------------•---- --------------•-----••-•----•------------------------------------------------•-----------------------------------------------------------------•------------ ------------------------------------------------ -------------- ---------------------------------------- ------------------------------=------------------------•-------------------------------------------------------------------------------------•------------ --------------------------------------------------------------------------•-------------•------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State haws., and rules and reggula/tions of the San Joaquin Local Health District. (Signed)---4A'C.fiGLc� --------------------------------------------r�'�". & — �� -------------------------------------------------- ----------------- ------{ wner and/or Contractor) BY: -,�' ' •- --- -------------------=---------------- -- ---------------{Title)- - ------- ------------------- - -- - -------------------------------------- (Piot plan, showing size of lot, locaAn of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY F APPLICATION ACCEPTED BY----- ------- ------------------- --f` ' 6---------------------------- •------------ DATE------ REVIEWEDBY--------------------------------------------- -------------------------------------- • -- -------------------------------- DATE--------- -- ---- ------ ----- BUILDING PERMIT ISSUED----------------------------------------------•-------------------------------------------------•-•-- DATE.-------- -- = - ----- --------------- Alterationsand/or recommendations-------------------------------------- ------- - ------ --••--------------------------------------------------------------- ----------------------•-•----------- -------•--- - -------r------•--- FINAL INSPECTION BY:--------- ------- ------------------------------------------------------------ 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 10-52 Revised W-2100