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1� r/ Q APPLICATION FOR SANITATION PERMIT Permit No. .f7Fkop - ' �� {Complete in Duplicate) / /II D • to Date Issued 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 complian with County Qrdinance N1�+4 _ (rjaF Q, cyst � l JOB ADDRESS AND LOCATION-------------- '-'`=R'-'----t- 3-- --��.�r�...-�e-...-__-��✓t��•r-r=_._5,,,._C�,.__��[:c�--=------...------------ y n M IIS-_� . Owner's Name-------4�' -trr�r-------- �11t� �: —dei Phone Address-------------- -- _---..------- ----- ------- ------------------------------------------------------------------------------------------- -------------- - Contractor's Name---------------------------------------- - ---- ...---------------------------------- Phone-------�_--��--�P.�-- Installation will serve: Residence ❑ Apartment House ❑ Commercial [I Trailer Court ❑ Motel ❑ Other-[ i_ Number of living units: � __ Number of bedrooms Number of baths'�Lot sizeE?Q_r_ ./, -_-______��_ _� �� Water Supply: Public system El Community system E] Private X Depth to Water Table,0�ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe,'*r Hardpan ❑ Previous Application Made: Yes ❑ NOX New Construction: Yesl$d—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-7Q'--_-_Distance from oun dation--Q-------------_-Materiaff ._y------------- -------- _------Aw No. of compartments__Zt___________________ � Liquid depth_--__ fir__ _-._ p y__ 4 __Ca acitt�it- _____ Disposal Field: Distance from nearest well_ 4? Dista3from ou_i dation-----e --------Distance to nearest lot line________�'� IAV' Number oli lines---..-----t------------------------Length of each line-----�Q------------Width of trench----s _ -- of filter material___ _ -----Depth of filter material-__- "......Total length-------°/_0_-_-____________________ Seepage Pit: Distance to nearest well---1-U_©I-'----Distance frRm''foundation__Y------------Distance to nearest lot iine___s�_- ____ 9 Number of pits.-_�_____________-__Lining mate ria l-�01� 14----Size: Diameter_�44f ..........Depth----1_42-_----------- ______ Cesspool: Distance from nearest well-----------------Distance from foundation------------------- material------------------------------------- El Size: Diameter------ -------------------------------Depth---------------------------------------------------Liquid Capacity gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- � ElDistance to nearest lot line------------ -------------------------------------------------..------ -------------------------------------------------------------- RemodLt p g (describe: � _ 1 _----------------------------- ----------------------------- t ---------------------------------------•----------------------------------------------------- ----------------- --------------------------------------- ----------------------- - ---------------------------------------------------------------------------------------------------------------------------------------------•------------------------------------------------- I hereby, cer fy that 1 h ye prepj6e application and that the work will be done in accordance with San Joaquin County ordinance ' ate aws, and 11ules and ons of the.San Joaquin Local Health District. (Signed)------- - = -------- = = t �} -,---.-------------------------- ---- -------�' r Contractor . ' - ------------------------------ -- --- _. GaM---------------- Title- -n- ------- -------------- (Plot plan, showing size of lot, location of system i r ation to wells, build" gs, etc., can be piAced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ DATE -------------------------- REVIEWED BY---------------------------------- DATE - - ----------------------- BUILDINGPERMIT ISSUED----------- ---------------------------------------------------------------------------------------• DATE.------- ---------------------------------------------------- Alterationsand/or recommendations---- ------------------------------------------------•-------------------•-------•------------------•----------------------•--•-----------•------------------- ---------- ----------------------------------------• ------------- -----------------------------------------------------------•-••---------------------•------------- ------------------------------------------------- ----------I------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------•-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------- --------------------------------------------- ---------------------- -------------------------------------------------------------- ------------------------------- ----" -. ----------------------------------------- ..- no `� i,w • r � FINALINSPECTION BY:r._ -- -------------------- --------------------- Date---- ----------------------------------------- ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100