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0 APPLICATION FOR SANITATION PERMIT Permit No. 4IDr (Complete in Duplicate) t �f}-TI" �Si7n1 -A} ,, . 1 Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct a d install the work her scr bed, This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION___-_-____ �/ TXrin na��1 _ 6fi-Y_tet. ------------------ Owner`s Name,----------------------------�- ,10 w Phone------------7------------------ Owner's ___.__�� Address f '.-- `1 rS7�� _ T,r-'-`'------------------------------------ Contractor's Name------------------------------------------------------------------------------------------------ --------------------------------------------- Phone------------------------ ---------- Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __f-- Number of bedrooms ---%'Number of baths -_-e�_ Lot size _- -�__x___ :a _�_____-______00000000-_ Water Supply: Public system ❑ Community system ❑ Private K Depth to Water Table .------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: YesK 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-40-If---- _Distanc oun�tion_ - _ _ - g from f/ 1�-------.Materia-- No. of compartments _.-. p �-- _--..__Size-�-X- -----Liquid depth---0000-- -------0000-----Capacity--- �'� Disposal Field: Distance from nearest well_60--------Distance from foundation_-'111 -----.Distance to nearest lot line----15----- Number o-i lines-----------2—------------____ Length of each line_______) ,Or _______-.Width of trench-------- Type 'r yp of filter materiaf_� _Depth of filter material___._I,�-_ ____-Total length--------- �_Z�_______________ Seepage Pit: Distance to nearest well_.__--_______-_-----Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits----------------------Lining material--.--------------------Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance from nearest well_________________Distance from foundation-------------------.Lining material---------------------------.__.______ ❑ Size: Diameter.-------------------------------------Depth----------------------------- ---- ----------------Liquid Capacity- --------------------------gals. Privy-, Distance from nearest well-------------------------------------------------Distance from nearest building--------------------------------...____..- ❑ Distance to nearest lot line------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe)--------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------- --------- ------------•-------•----------------------------- ------------ ------------------------------------ --------------------------------I--------------------------------------------------------------------------------------------------------------- --------------------------------- I hereby ' y that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, tate a�,:and-, I and r ulations of the San Joaquin Local Health District. (Signed)--- -.--__t_�__.'.-._ ------------------------------------ --------------------------------------------------------------------(Owner and/or Contractor) By:---------------------•-•---------------•--------------- ----------------------------------------------------------------------------(Title)--------- --------- -------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ==R ---- - �----------------------------------------- DATE------- fa ------------- REVIEWED BY------------------------------------- --------------------------------------------------------------------------------------- DATE------------------ BUfLDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:_ ------------------------ ---------- by--J' ---- - -- - ----------------•-------••---------- ---------------------------------------I----------- ----------- ---- - - 9 ---:::h . ----------------------- ------ - - 000 0---- --- .. -S_ --- ---------------- ------------------------------------------------------------------------------------- '----- - ;/ 0000- 3 0000-- y - FINAL INSPECTION BY ---- ------------------ ----------------------------- Date....--�---r----0�2'- -S t 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 10.52 Revised W-2100 1�