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APPLICATION FOR SANITATION PERMIT Permit No. -- ------.--r-____ (Complete in Duplicate) � Date lssue� __��_�___________ 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. 549. JOB ADDRESS AND LOCATION------- 631-- arQ- Stre-et ---5t0_Ckt_Qn Owner's Name------------------------------------------M?s._-.0re-r-tr-rude�---at-wwar—t----------------------------------------------- Phone---3-r'A 5a4--------------- Address-----------•----------------------------------------•-63-3---10.....O_r_t_rU_d_0---5-tra e-t----------------------------------------------------------------------------------------- Contractor's Name--------___------------------- '------A,____AFtRI5U---4_8i -THIS-s----SLC-A------------------------------ Phone-----9fn9_6Q7------------ Installation will serve: Residence JK] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ._____ Number of bedrooms -------- Number of baths -------- Lot size __________________________________________________________-_ Water Supply: Public system ❑ Community system '❑ Private ❑ Depfh to Wafer Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ 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-----------------Distance from foundation--------------------Material------------------------------------------------- El No. of compartments--------------------------Size--------------------------------Liquid depth------------------------Capacity----------------------- Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line----------------- t ❑ Number of fines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well---------------------- from foundation------------.------Distance to nearest lot line___________-_____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest wel1-----------------Distance from foundation Lining material__--_--•----------__---____-_________- Q ❑ Size: Diameter------------------------------ --------Depth----•.._..--------•------- •----- -----------------.,Liquid Capacity---------------------------gals. Privy: Distance from nearest wef-------------------- __--___----____---_--_Distance from nearest building_________________________---_---__-_-__. ❑ Distance to nearest lot line------- ---------- ---------------- ------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe):Pq jt___t0--_cover..rgpg_ Y'__g_f_..6_;pKgr---JILJIe-___�C� -_metes---Re-3at�-c---tank---t-o----Qxaatyng -spa per_..------U-Sum --and-,pnev;-aus-- -------- --- -a-rL,-._done--- Parr_izh &---ions, ara._,n&r_e_3_y -AO_jng...t1A_s___XQrk__2.t.---roquexst---0-i---Mr-8--------S-t*-W.Q rt-- &---ne-u*-r'---------- WP cQd PrItita -4ly4eEpiepBrad p pli at on md'$ha*7 9 vmr):ro,1111metcMe#in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)---D_ --A• P ---r----•---------•----•-------- (�� Contractor) By:.-. ----- To ------------------------------------------------------- --------(Title}-K8t_j.I�atnr--------------------------------- (Plot plan, sho 'ng size of lot, locsystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- --------------- DATE_ `� REVIEWED BY-------------------------------- — r --------------- DATE -- ------------------------------------------ BUILDINGPERMIT ISSUED t----•-------------------- ----------------------------------------------------------- DATE----------- ----------------- - Alterations and/or recommendations:--- ---- --- - ----------------------------------------------------------------------•------------:�-.•-------- ---•---- --------------------------------------------------------•--..--------- A)-0-- --------- 8 � . �� .......-------- � y-� ?�------= " ----------- ------------------------ ----------------------------------------------------------------------- --------------------------- V . -------------------------- ------------------ ----------------------------------------------------------------------------- - FINAL INSPECTION BY:----------- ------------ -- ----------------------- Date----- - -- --- ------------------------- 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 B-51 Revised W-2100