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�ff� ��YA I APPLICATION FOR SANITATION PERMIT Permit No. __ .__ -- --------- J ` f, (Complete in Duplicate) �/ VJ_J �( Date Issued -_.._`___._Tf_._� ; Application is hereby made to the San Joaquin Local Health District for a-permif to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. �— n - --JOB ADDRESS AND LOCATION-----��-- - -A �� -----------------------------------2J1 �'----------------- Owner's Name �� _ _Ptrss_d -- - ---- --------- Phone------------------------- -- Addres's-------------------••----------------•----------------------------------------------------- ------•---------------------------------------------------------- -----------------------.------------------------ Contractor's Name------------------------- ----I--7"d--�--� ---�'`----- ------------ ------------------------------------------- Phone.---------------------------------- Installation will serve: ResidenceApartment House I-] Commercial E] Trailer Court E] Motel E] Other E] Number of living units: ___1_._ Number of bedrooms -__2_ Number of baths .-/-- Lot size ---------->�_l_X_--7-3______________________ Water Supply: Public system ❑ Community system ❑ Private Depth to Wafer Tableo-------- ft. Character of soil to a depth of 3 feet: Sana ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe Hardpan [] I Previous Application Made: Yes [❑ No V New Construction: Yes k No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: w (No septic Tank•or cesspool permitted if public sewer is available within 200 feet.) Se Tank: Da stance from nearest well-- __�___-Distance from foundation------/_�n_ -----Material-_ _________- No. of compartments--------- -----------. X �___Liquid depth---------i�-- -----------Capacctyj?'-p7-----= Dispos I w Field: Distance from nearest well----SQ.. _.Distance from foundation____!-1-_____....Distance to nearest lot line____9__.._-.. I Number o-i lines_____________ ---__�_}_�_____�___ Length of each line--------/{ ., __.__�_...Width of trench--------- -1 ri '^'_____-_____ Type of filter material_ _ Depth of filter material----------A?-------Total length-------------------- -3__._________._ � ) Seepage Pit: Distance to nearest well----------------------Distance from foundation_________-__.._.._-Distance to nearest lot line---._____________ ❑ Number of pits----------------------Lining material---------------------- Size: Diameter_----------------------Depth--------------------------------- Cesspool: _p Distance from nearest well------------------Distance from foundation--------------------Lining material_________________._______.__.______- ' ❑ Size: Diameter------ ------------------ Depth----------------------------------------------------Liquid Capacity__ ----gals. Privy: Distance from nearest well____---------------------------------------------Disfance from nearest building------.---------------------------------- .�: 11 Distance to nearest lot line-------- ---------------------------------------------------------------------- -------- ------------------------------------------------- Remodelingand/or repairing (describe):--------------------------- ----------------------------------------------------------------------------------------------------------------------------- -----------•-----------------------------------------------------------------•------------------------------------------------------------------------------------------------------------- •------------------------- -------- ---- ---- - --- -- - - -------------------------------------------- -------------------------------------------------------------•--------------------------------------------------------------------------------------------------------- ---------- ------------ ------------------------ I hereby certify that I have-prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed) _.___.____ _____________________ Owner and/or Contractor By:/]. ------- ----- ----- (Title) (Plot plan, sh, ing 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--------- �•--------------------------------------------------------------- DATE-------- f 7-------------------- REVIEWEDBY---------------------------------------- -- ------------ ------- ----------------------------------------------------------- DATE--------------------• �-------'"�----- BUILDINGPERMIT ISSUED =----------------=----------------------------------------------------------------- DATE---------------------------------------- Alterations and/or recommendations------------- --------- ----- ------ ---------- --_--------------------------------------------------------------------=------• - ------------------------------------------=------------------------------------------------- --------------- --------------------------------------------------------------------------------------------------------------- -----------------------=---------------------•-----------------=------------------------------------------------------------------------------------------------------------------------------------------------------------- - ---------- ------------------------------- -- ------------ -------_------ - --------------------------------------------------- --•----- -• ------------------------------------------------------------------------- - ii'�• 1��, arae.. - r c " Date----- ------ - " - ---- -- - ---��- --- '---------- FINAL INSPECTION BY::'............... . u _ 1 . 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 4 ES-9-2M 0-52 Revised W-2100 w-