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f53 . 1,0// r'J APPLICATION FOR SANITATION PERMIT Permit No. 'y (Complete in Duplicate) Date issued Applicaa-ion is here 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 Ordin nce No. 549. JOB ADDRESS AND LOCATION - ______._ --_ ---- 'P ------ ,0, ,--------------------------(--�------------------------------ Owner's Name------- .--------•------------------------------------------------- ------------------ Phone I-- Address........_........:�-.3--7 hk / Contractor's Name.._=---- ____ -'/��______ -__-.-__- Phone___.' ll? Installation will serve: I Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel (] Other ❑ Number of living units: ___I___ Number of bedrooms __��_ Number of baths I_____ Lot size ---7,-,r---X__f ---------________________________ Water Supply: Public system'[] Community system [21"'Private ❑ Depth to Water Table *�_ ft, +s Character of soil to a depth of 3 feet:' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ['New Construction: Yes ❑ No ®-� TYPE OF INSTALLATION AND SPECIFICATIONS: M (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) Septic T nk: Distance from nearest well-----------------Distance from foundation--------------------Material-__________.__________.___________-------------. ❑ No. of compartments--------------------------Size-----------•--------------------Liquid depth--------------------------Capacity----------------------- W Disposal Field: Distance from nearest well..................Distance from foundation--------------------Distance to nearest lot line________-___----- ❑ Number of lines---------------------------------- Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material____-_____.________Total length_____--_______-___-_______:__________L_ Seepage Pit: Distance to nearest well-----.----�--___-Distance fr m oun ation-----Y�_.......Distarj�e to nearest lot line_ -__L_�___-_ [ Number of pits___.____-----------Lining material._G_I_�_�Size: Diameter-__-73_.________.Depth....a r.2________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------.------------ -• .•z. S.ize:Diameter--------------------------------------De th----------------------------- -------- -- . e----Li Liquid Capacity.. gals. ❑ .n. p q p Y Privy: 'Distance from nearest well---------------------------------_____-::_____._Distance from'nearest building,-,,-------------- __. __ ❑ Distance to nearest lot line_ ______________ -------- ------------------ - ------•------- • -------•--•--=---------------------- ---- -- Remodeling and/or repairing (describe):--- -• -- -- ---------------- 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) ___G*mr and/or Contractor By-•------••- --- - - ------ --- -- -- --------------------------------------------------------------------------------(Title)--- ------- ` `"-'7--------------------- (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 W-�_ -OM1. - ----------- ------- DATEJ?/ Q- ----------- REVIEWEDBY----------_J----------------------------------- --- -------- ----------�9-------------------------------- DATE---------•- -----=-- ----•-------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------------------------------------------------- Alterations and/or recommendations:-------------------------------------------------------------- -••----••--•---------------------------------••--------------------------•-- -----------•-----------------------------------•----------------------- ---------------------------------------------------.-----•----------------------------------------------------------.------------------------- ---------------------------------------------------•----•----------------------------------------------------------••------------------------------------------------------•--•------ --------------------------------------•- -----•----------------•----••-•------ '--------•-----------•----------•----------------•---------------•--------------------------------------------•-----.----••---------------------•---•----------•-•-..----- FINAL- INSPECTION'. BY:::-. r Date-----=--- - ------77;J ------------ 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 Revised W-2100 x-v