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APPLICATION FOR SANITATION PERMIT Permit " 13 (Complete in Duplicate) .,� Date IssueY- -/- __. _57- g �3 S� r Application is hereby made to the San Joaquin Local H alth District for a permit to construct and install the work herein described. This application is made in compliance with County r inan No. 549. 1. JOBADDRESS LOCATION------ ------ --- -- ------- - - ------- ----• ------------------------------------------------------------:------- ------------------------------ Phone__ y_-.�OO Owner's Name---- --------- - �.-. --- -------- - -- -------------------------------------------- --------------------------------- ------ Address----- -- ----= r. +-----•---------- ------------------------------------------------------------------------------------------------ •---------------------------••--------------- Contractor's Name---- 1L-7� ----- ---------------••-------------------------- ---------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Mot tl ❑ Other P Number of living units: umber of bedrooms _k_ Number of baths __./__ Lot size p50- X______�_Z!�- ------------------------ Water Supply: Public system Commu�n-ify syssystem ❑ Private ❑#bepth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam Clay Loa, ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ �a Z( New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is availablewithin 200 feet.)�r,, Septic ank: Distance from nearest rest well _Distant tfro joue#ion___�Q___ '____.Mat$ri _______ _______________ No. of compartments �J�� - Size-- - -�xc-----..Liquid depth' �F-- ----------- CapacitY Dispos Field: Distance from nearest 114 Distance from foundat-o _--_�_ __ __ istance to nearest lot li _ -r-- 1 Number of lines_____I_.____ ------ Leng6 of each line__--` �-7Width of french_________Z -_ Type of filter materi . __ _ _:y1[ti--Depth of filter material_______.al.p._ ____Total length______________f�___ _________________ Seepage Pit: Distance to nearest wel_�__________________Distance from foundation_____________-_____.Distance to nearest lot line------- ❑ Number of pits----------------------Lining material -_-_-----------. .---Size: Diameter-----------------------Dep th--------------------------------- ol: Distance from nearest wel --------- from foundation___._..________._..Lining material____________________________________ Cesspo , Size: Diameter Depth -------------------------Liquid Capacity-------------------- -------gals. ❑ -----�;A----- Privy: Distance from nearest well------------ ----------------Distance from nearest building__________.__.______________---_._.__._._. ❑ Distance to nearest lot line------------------------ -------------------------------------- ------------------------------------------------------------------- - Remodeling and/or repairing (describe)s-------�----------------------f-- -- --ON_ -------..----------------------------------------- -------------------•----------------------------------- ------------------------1--------------------------------------------- -----•-------------------------------------------- ------------•-••--------.._..----------==`' ---:-------=----------- --------------------------------- •------------------------------- = ---------------------------------------------------------------- --------------- I hereby certify that I have prepared a this ppl'cation and Aaf the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations f the San Jo Fquin Local Hedlth District. (Signed)--Z-`Y i 4.��_.A. � -- -------- - ------------ --------------------------------------(Owner and/or Contractor) B - - ----------•--------------------------- ---------------------- ------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells,%buildings, . fc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- ------------------------- ------------------------------------------------------------------ DATE---- ---------------------------------------- REVIEWED BY--------------------------------- ------- ---------- - ---------------- -------------------------------------- DATE-- ----------------------------------------------- BUILDINGPERMIT ISSUED---------------------------- ---------------------------------------------------------- ---------- DATE-- -- Alterationsand/or recommendations--------------------------------------------------------------------------------------------------------------------------- ------------------------------------ ------I-------------- -------------------------------------------------------- ---------•------------------------....__ ------------------------------ ------------------------------------------------..-_...----------------------------....----------------------------------------- --------------------- ----------------------------------------------------------------------------- -----------------------------------11---------------------------- ----------------------- --------------------------- ---------------------------------------------------- ------------------------------------------------------- FINAL INSPECTION BY:. ------- ----------------------- -• ••---- Date--------- - ------- -------�- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West CA Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M I0-52 Revised W-2100