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APPLICATION FOR SANITATION PERMIT Permit No. __ 5�.3kf_ [ (Complete in Duplicate) - y/ /�. }: Date Issued _l l- 4A'plica4-ion is hereby made to thi e San Joaquin Local Health District for a permit to construct and install the work herein described. application is made in compliance with County Ordinance No. S49. JOB ADDRESS AND LOCATION_ Z7� - .... - -S �/j� --- -----------=- ---------------- Owner's Name_.-- -.- -= on �l ..__.... Ph e-� s��aZ.� Address -- --• ---------------------------------------------R - --------------------------------- -- - ---------------- Contractor's Name y�Ctli� n,P -� - ----- ii - Installation will serve: Residence-R'artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _c ' + -- Number of bedrooms�.. Number of baths cr�-- Lot size ------- Water Supply: Public system &101�c_ommunity system ❑ Private ❑ Depth to Water Tables-ys ft. I Character of soil to a depth of 3 fee'f: Sand E] Gravel ❑ Sandy Loam E]; Clay Loam ❑' Clay ❑ Adobe Hardpan ❑ Previous A lication Made: Yes ' pP ❑ �No New Construction: Yes ❑ No TYPE:OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ep Tank: Distance from nearest well-----------------Distance from foundation-------------------Material----.__---.---_____. No. of comparfm;encs------------------ - _--.- - ----Size---------------- ---------------------- ------Liquid depth--------- -------------- Ca Di s Field: Distance from nearest well-----------------Distance- from foundation---------------------Distance to nearest lot line---------------_ Number of lines---------------------------- -----Length of each line --------------------------Width of french.---•------•---------------- - Type of filter material--------------------------Depth of"filter material-----------------------Total length---------------------_-------------------- See�p'a1g�e Pit: Distance to nearest well/44 -Distance from foundation_,/± _t.__.-..Distance to nearest lot line- Z__ I� Number of pits- .. _--------_Lining mate ria L_,�_-__-Size: Diameter--^73-3." Cesspool: Distance from nearest well----------_.----Distance from foundation------------------ Lining material-----------------------_-.--_____-_-. (V ❑ Size: €diameter---.l-------------=------- ---------Depth-------------------------------- --------- Liquid Capacity gals. 'U t Privy: " Distance from nearest well--------------------------------------------------Distance from nearest building.__-.----__-------_.-----------_ ❑ Distance to nearest lot line--------------------------'_•-------------_----- -------------------------------- Remodeling and/or repairing (describe):--------------------------------------------------------------------- I - --------------------------------------------...----------•------------------------------------------.---------------------------------------------....------------------------------------------------------------------ ------------------------------------ ----------------- I------ ----••--------------------•---•----------------•-----------------------------------------•-----------------------•----------------------------------------- I hereby certify-that-I have prepared this application and that the work will°be done in accordance with San Joaquin County ordinances, S e laws, and rules and'reguiations of the San Joaquin Local Health District. -----V— --- - {Signed)- ------Owner and/or Contractor) By: //�...-_ �-;�h,r ----------------- ---------------------------------------------{Title) 1 •--------------- --------- ------ (Plot plan, 'showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.--- ---- -- DATE-.--'-a. ---- -- -- ---- -- ---- - 'REVIEWED BY------------- � � DATE------- ------ - --- ----- -------------------------------------- BUILDING PERMIT ISSUED---------------- ------- -- -----------------------------------_-----------------• DATE---------- - Alterations and/or recommendations--------=----------- ---•-----C"�._.. . ..---- ---- = * ------------------------------------------ ----------------------------------------------------------------------------------------- -- FINAL INSPECTION BY:-_, �,t a�s..,== Date------. ------------------------------ ------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT ° 130 South American Sfreet 300 West Oak Streef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5--9 ,<sag5 arw000