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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in in Duplicate) G�I Date issued _-[_/_�'�'•5,� , Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal[the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION &/,__A__0 �a D Ii JJ Q --•------------------------------------------------------ Owner's Name---- r1.s__ - 1._ ----- - - ----- --------- --------- Phone- ---`j----`��---��--�-�� --- Contractor's Name--------- •--tA_)-- ---kn--••----Y-- ----- Phone Installation will serve:, Residence Apartment House ❑ CommercieE ❑ Trailer Court ❑ Motel ,❑ Other ❑ Number of living units: J____ Number of bedrooms _A___ Number of baths ---/___ Lot size Q_-�(- I ----------------------- Water Supply: Public system �ommunit y system [:] Private ❑ Depth to Water Table -------- ft. � Character of soil to a depth of 3 feet: SandGravel [I Sandy Loam❑ Clay Loam Clay [❑ 'Adobe 2<Hardpan ❑ Previous Application Made: Yes ❑ No ' NeAcm truction: Yes ❑ No0 1 \ ]/J� TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) E SeptiTank: Distance from nearest well_._`--- Distance from foundation__. O•./__ f-• - - .___Material----- r No. of compartments--,------r..__----- * x rJ ----- S e Xqy - `'"Liquid depth_- - ..Q---------- Capacity -------- Disp Field: Distance from nearest well ----.-Distance from foundation__.-�D+ ------;Distance to nearest lot line______.___ Number of lines----------k Y-_I- Length of each line--------- -_ ' g ----;:---- Width of trencn.-__--- ZJI ------------ Type of fitter materiaL._y �--__-Depth of filter material--------- ---_ Seepage Pit: Distance to nearest well_.---------""!!!�'"_`Dis-fiance-from°foundation"' '""""" ' �� fi r--------------.Qistanco.to nearest lot line----------------- N Number of pits------------------_--Lining material---- ------rte._-Size: D,iameter------------------- - •a►. Depth--------------------------------- Cesspool: Distance from nearest well________________Distance from foundation _---- -___.Linin material___---____.___________ s�' s g -------------- ❑ Size: Diameter--------------------%,------------- Depth-------------------- }-----------Liquid Capacity----------------------- ----gals. Privy: Distance from nearest well----------------------____-------_ Distance fAm nearest building - ------ ---- ---•--- ------ ❑ Distance to nearest lot line ---__ -- ----- - ---- 1= # ------------ - --------------- Remodeling and/or repairing (describe)__________________________ f ---------------------------- ------ ----------------------------- --•---------------------- -------------- °-•------------------------------- I --------------•------------------•-------------- _ -----.-_ -=-----------'_----.----------------------..-._---.._----••---•---•--------------.._-----__------•------•-----------•-•---------------------------------------------------------------------------------- ...... I hereby cer+ifyothat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rules and regulations of the San Joaquin Local Health District. t ,. (Signed).� - --------- 1 Y -------- ---------------------------------------------------- By s {Owner and/or Contractor) Plot '" __{Title} I-- - + __ pan, 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 REVIEWED -- DATE------------- ------------ ------- -- ---------------------------- REVIEWED BY---------'------ -- -- , ES__ ------=-------- --- ----- -------. DATE BUILDING PERMIT ISSUED.--------- ----------------------•------------ -- -------------- ---------------------------------------------•---------------------- Alter i n an or.recomme a_tions:---------- r---------- : •- DATE--- �� / v1 t f- .4 c--------------. !• t - - -`.`1 -----••------- r ----______'fM --------------------------------------- -------------- __s FINAL INSPECTION BY: ------------------- ----•---- Date------ ------------------ ----------- --------- - ' --------------------- )SAN-_`JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street "" ;" +_300 West Oak Street 132 Sycamore Street 814 Norah "C" Street +Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M 10-52 Revised W-2100