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'�- APPLICATION FOR SANITATION PERMIT Permit No. .1Y QCs (Complete in Duplicate) .0 b v Date Issued __I/--_... -:sem._ Applica}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 County Ordinance No544 JOB ADDRESS AND LOCATI N.._.f.{''` ,. e4_Aot-�----------- Owner's Namee--j47MV- ----- -----^----------------------------------------------------------------------------------------- Phone------------------------------------ Address------Contractor's Name Name-- --------------- ----------------------------------- Phon,61AIII Installation will serve: Residence 4—Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _/-_ Number of bedrooms _-Z Number of baths .--L Lot size ----V D-_'_, ,..1_ -.�''------------------ Water Supply: Public system a-jCnmmunify system ❑ Private ❑ Depth to Water Table _ .0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No [j--ITew Construction: Yes ❑ -No TYPE OF INSTALLATION AND SPECIFICATIONS: Y (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank; Distance from nearest well------------- Distance from foundation-- -._.----Material--------------------------.__--__--_-_---.-----. No. of compartments-------------------------Size-------------------------------Liquid depth--------------- ----------Capacity----------------------- Disposal Field: Distance from nearest we€i-----------------Distance from foundation--------------------Distance to nearest lot line_-.____---_---_- . �y Number of iines---------------------=-------------Length of each line..............................Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material----------------------..Total length_--.----_-----------__.-___.__--.__-----__ Seepage Pit: Distance to nearest well__ ._._Distance f m __fo�j��fdation_--I_Q-_�---.Distance to nearest lot line-___ (� Number of pits-------I._----------Lining material_. Tr_�-._Size: Diameterj3__._e..--------Depth-.�� \ Cesspool: Distance from nearest well-----------------Distance from foundation--------------:------Lining material---------_-----------------.____-__-- ❑ Size: Diameter.------ . .-------------------------- Dept ---------------- (� ------------------------------------Liquid Capacity----------------------------gals. Privy Distance from nearest well----------------- _--_---------.-.___-_-.-.._Distance from nearest building----------------------------..---__----- ❑ Distance to nearest lot line---------•--------------------------------------•------ -----•-...---.------------------------------------------------------------------ Remodelingand/or repairing (describe):------------------------------------------------------------•...................-------------------------------------------------------------- h -•--.----•--•----------------•---------.-....----•---------------------------------••---------•-------•---------------------------------------------------------------- -----------•---------------------------------------- --------------------------------------------------------------------------------------- ------------------------------------------••--------------------------•------•---------------------•------------- -•--------------------------------------------------------------------------------------•----------•---------------- --------------------------•---•---------------.-...-------....-----•--------------•----------•--------------------------•-•-------_---------------------------_-----------••-•------------•----------------------- 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)... ------------- -- - - - --------- ---- --- - -- ----I'®w'ner�wder Contractor) - gY= -- ------------------------------------------------------(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- ------------------- ------ ----------- -- ---------------------------------------- DATE—-------•-------------------•---- ----------------- -- - - ----- REVIEWEDBY------------------------------ - - ----------------------------------------- ------------------------------------ DATE-4� .------------------------------------------------- BUILDING PERMIT ISSUED----------------------------------- -- - DATE---- --.---------------------------------------------- Alterations and/or recommendations:-- ---------------- ------------- -------------------------------------------------------------------0---------...-..------•------------------------- ----------------- ----------------------- ----- - --------- ------------------ _.... } � G`------ -- ---------- ---------------------------------•-•- ------- ----------------------------- ----------------------- ----------------------------- --------------------------------------------------------------------- FINAL INSPECTION BY:--------- ----------- - - Date---------5------------------------------------------------------------------- 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 Ems'-9-2M 145446 ATWnDD 12.54