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APPLICATION FOR SANITATION PERMIT Permit No.A4577 U _._._. (Complete in Duplicate) Date Issued 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, JOBADDRESS AND LOCATION-------------------0�41-------- SA-r-I-mi----------------------------------------------------=------------------------------------------ 1 Owner's Name---------------------- _ Phone------------------------------------ _; J Address-----------•-- --------------------------------------------------------------------------- Contractor's Name------------- ------- ------------------•----•------------------------------------------------------------------------------------------- Phone----------------------------------- a Installation will serve: Residence WT Apartment House E] Commercial ❑ Trailer Court E] Motel ❑ Other E]Number of living units: -------- Number of bedrooms ------ - Number of baths -------- Lot size -----------------------------------_________________________ Water Supply: Public system X Community system ❑ Private ❑ Depth to Wafter Table -------- ft. i 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: (No septic tank or cesspool permitted if,,public serpr.is available within 200 feet.) Q� F W_ , Septic Tank: Distance from nearest w II-__ ______Distance from foundation_____ 4__________Material-______'_I�--------------------- No. of compartments----------Z-------------Size-----57__K__'�.-) -__.___Liquid depth----------Lk...---___Capacity.....y.'T_j__,f4s�__N Disposal Field: Distance from nearest well---*:____.__.Distance from foundation- ---- _.Distance to nearest lot line____ Number of lines------------- ------y---�;--------Length of each line------------�4_---r-----Width of french,---------�1��----------------- Type of filter material----- t�_"Ylc _-Depth of filter material-___.___. �j________Total length---.......... ------ --------------- F Seepage Pit: Distance to nearest well----------------------Distance from foundation-----------.------- Distance to nearest lot line--___...______.__ a❑ 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----------------------------------------------------------------------------------------------------------------------------------------------- 1. Remodeling and/or repairing {describe) f WW --- b{ .f C: � --------------------------------------------------------------------------------------------------------------------------------------- -----------------•-----------------------------•-------------------------------------- 4 __ _ _ ________________________________________________________________________________________ _________________________________________________________________________________________________________________ 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, nd rules and rgulati s of the San Joaquin Local Health District. Ir A (Signed)-------- ----- -- fl1 ----4-------------`-�---------------------------------------------------------------------------------.(Owner and/or Contractor) By:--------•---------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plat 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--------------------•--------------------------------------- BUiLDING PERMIT ISSUED---------------------------------------------------------- -----------''-------------- DATE-------------------------------------------;----------------- Alterations --------- --Alterations and/or recommendations:-•-------- ------------ -- --------- ----------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------•------•-------------------------------- -------------------------------------------------------------------------------------------------------------------------- ----------- ----------------------------------------=---------------------------------------------- G=A FINAL INSPECTION BY:..------- Date 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--9-21v1 I0-52 Revised W-2100