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APPLICATION FOR SANITATION PIRMIT Permit No. (Complete in.Duplicate) p.S ,... Date Issued -------1___'•------ Appiica{ion 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 C y Ordinance No. 549. JOB ADDRESS AND LOCATION________ -------V '�---•-- - - !'----------- ------- ------•------------'----•------------------------------------ r _ Owner s Name-------- / ------ Phon - ---- ------- r e_� fw. +� •---- ----------•------ Address------------•------------•-- C� I --- Phone. Contractor's Name_..___._.. �f�•-.�8 ��ig ___ .- Installation will serve: 'Residence Apartme'1.t'Hd"e•0-"-Commercial-❑• Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __L_-- Number of bedrooms -_aYv'�!_�__ Number of baths _ ___ Lot size _____ ---Xa-l�-------------------------- < , 1 o Water Table/_P__ ft. Water Supply: Public system ❑" Community system ❑ Private �bepth � A `. t *.4114'` . 11 t ! ' Character of soil to a depth of 3 feet: ' Sand ❑IN Gravel ❑6 Sandy'Loam ❑` Clay Loam �] Clay ❑ Adobe �Elardpan ❑ Previous Application Mader Yes ❑�N6� New Construction: Yes EKNo El �.,;. TYPE OF INSTALLATION AND SPEClF1CATIONS: E' (No septic tank or cesspool permitted if public sewer is available within, 00 feet.) Septic Tank: Distance from njarest well__t D5`__Distance f;om'foundat7on___J_O:�:::-_.Matlial___ s _'-_-- No- of compartments------�r----------- --Size---3G___Xyd____ "`��`Liquid dep.th---- -------2----------- Disposal --------- CapacitY---�`S^4----- Disposal Field: Distance from nearest well-174------Distance from foundatilon-----�d____ _.Distance to nearest lot line____'________ Q/ � .301_.Width of trench-----a-Y- Number of linesl......... Length of each line_ F- Type of filter material---_-r}_'-h�a---------Depth of filter�materi�al---- /k-�-----!--Total length------ ---��---------�------------ -*_ L6ndation_______________:-.Distance to nearest lot line-______.______--. S Seepage❑ Pit: -Distance lumberr of n+arest-well------------Lining mDateraial efrom-fou-- Me: Diameter---------------------Depth-----:--------------------------- � p p f aY'ion -�� --.Lining material--------------------- - Cess Cesspool: Distance from nearest well_______ ____ __ Distance-from:found T❑ Size: Diameter- ---------------------- IDepth_ -41 - Liquid Capacity gals. r fl y; 'tante from nearest well-------------------------------------------------- from nearest building 9------------------- Priv Distance to nearest lot line - = -----------------•--•---------------------------------- -- ------ •---.'s---------- �. Remodeling and/or repairing ( ) � y� x - - --- ------ *:repared -----------•----------•-----------------------••- -------- -------.------------------------------------------------ I reby certify that this application and that the work rn(ili be done in accordance with San Joaquin County f ordinances, State laws,` and rules-and regulations of the San Joaquin-Local Hitalth District. R (Signed).....- ------------------ -------------------- wner d/or Contractor) t By:--_------------ --� - ----- Title .. r I I (Plot plan, showing size of lot, location of system in re tion to wells, buildings,uetc., can be placed an reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ___ ______________________________________________ DATE'--4- - ATE -------------------------------------------- REVIEWED BY �� DATE---�_ ------------- REVIEWED PERMIT ISSUED----------- ----------------------------- ---- IIIA DATE ��-•.•-------------------------------------------- -- Alterations and/or recommendations----=------------------------------------------------•----------•---f---------------------•-••----------------•-•--•------------------------•-•---------•- 1111 - ---------•------•---•------------------------------1111----------- --=------------------------------••--------------•••--------• --•---- --------------------------------- ----------------------------------------------------------------------------------------- -------•------------------------------------••--------------------------------,---------------------------------------------------------------•--- ----------------------------------------------------------- ----------------- ---------------- FfNAL INSPECTION BY:. Date.----------------- ----- ----------------------------- ------------ --------- I SAN JOAQUIN LOCAL HEALTHiDISTRICT � 130 South American.Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Mentlea, California Tracy, California 4 I t, ES-4-2M Revised W-2100 '