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�fV �)1 .. ��, ? APPLICATION FOR SANITATION PERMIT Permit cam- -------- -- t (Complete in Duplicate) 6 Date Issued // a/25_1 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 compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION. 172-5 Z_.__.P_:Av-I- -t-------------------------------------------------------------------------------------------------------------- Owner's Name------ ---------------------------------------------------------------------------------------------------------- Phone--- 7-7124- ------- Address---------x-725---E-.---p3-ahat------------------------------------------------------------------------------------------_------------------------ ----------------------•------------ Contractor's Name----------� 1ta-------------------------------------------------------------------------------------------------------------------- Phone----- — ter?------------ Installation will serve: Residence M Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___1_ Number of bedrooms __2__ Number of baths _1____ Lot size _______________________________---_ Water Supply: Public system 0 Community system ❑ Private ❑ Depth to Water Tabl,-,90ff. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [3 Hardpan ❑� Previous Application Made: Yes ❑ Nom New Construction: Yes ❑ 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_________________Distance from foundation-------------------.Material____-__________.------.-____________________- EXisU:TG No. of compartments-------------------------Size------------------------------.-Liquid depth--------------------------Capacity----------------------- Disposal Fie4d: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----------------- EX 311,11L; G Number of lines-----------------------------------Length of each line------------------------------Width of trench-------------_--------------_--... Type of filter material _____________________Depth of filter material----------------------- ofal length___________.______________________________ Seepage Pit: Distance to nearest well_____S3.CaP-----Distance from foundation______ -----------Distance to nearest lot line---------51____ J Number of pits---------3-----------Lining material___-.s ---Size: Diameter------36 t..........Dept h-------].Q i__________________ Cesspool: Distance from nearest well---------------._Distance from foundation--------------------Lining material____________________________...._____. ❑ Size: Diameter--------------------------------------Depth---•------------------------------------------------Liquid Capacity----•-----------------------gals. Privy: Distance from nearest well__________________________________________ ____Distance from nearest buiiding------------------------------------------ F1Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------------- ---------- ` Remodeling and/or repairing (describe)------------------Pr] :1"X11: _j ��__n '.__;��_e_�? ,:. __.r? , --- --- �C1i�r1 .•��3--------•---. E?_---�11i ------------------------------------------- --------------------------- ---------------------------------------------------------------------------------------------------------------•--•-------------------------------------------•--------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)----------------------D-C.1ta--------- ---------------------------------------- ------'------------------------d---------- --^ -------------------(Owner and/or r Contract �1 �' By. ---- ----•--------------- .._-------(Tale)------QYL- - -------------------------- ---- (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 -- DATE--- --------- -------------------------- REVIEWEDBY--------------------------- `--------------- ---------- --------------------- -----------------------. DATE- ----------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------Z---------------------------------------- Alterationsand/or recommendations----------------------------------------- ---------•---------------- -----------------•-----------------•-------------------------------------------------- ---------------------------I------------------------------------------------------------------------------------------------------------------- --------------•----------------------------------------------.._... .... ---------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------_------------- ----------------------- ---------•------------------••---------------------------------------------------------------------------------------------------------------------------------------------------------------I-----------------------------------•-- FINAL INSPECTION BY: --------- Date-----_71fol �- --------- -------------------------- 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 8-51 Revised W-2100