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APPLICATION FOR SANITATION PERMIT Permito.N _ __g_ ____-_ 5 3� _. {:(Complete,in.Duplica+e) 1 p': Date Issued ---'f Application is hereby made to'the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 542 JOB ADDRESS AND JLOATION______._ D� , (/ �--a" .�i? ----------------- Owner's Name Ph • - - . � -- ------- - --- --- -------- ----------------- - -- one----•------------------------------- - ----------- _ ---------•---•--- Address------------- W Contractor's Name 's • Phone�`�_----- Installation will serve: Residence ApaTtmehtTHouse'❑"Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -. Number of"bedrooms __oz Number of baths _______ Lot size _-____ _.___ fX ----- � ------------------ Water Supply: Public system [P�ommunity system ❑ Private ❑ Depth to Water Table yS_ f[, Character of soil to a depth of 3 feet! Sand []� Xa&vel ❑ Sandy Loa l E] Clay Loam E] Clay ❑ Adobe [B-"Hardpan ❑ Previous Application Made: Yes E] No �f New Construction. Yes ❑ No 2---rHA/VA: Yes ❑ No ❑ TYPEOF INSTALLATION AND SPECIFICATIONS: t (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) pticj Tank: Distance from nearest well_________________Distance from fol ndation__.________________.Material_-____-,________ No. of compartments Size_. Liquid depth__ -------Capacity-•---- --------------- spo Id: Distance from nearest well-----------------Distance from foundation___________________Distance to nearest lot line_________________ Number.of lines_________ --- r -- ------------- - --Length of each line------------------------------Width of #rencn---------------•------------------ Type of filter maferial?- ..-- Y -_:--_-Depth�of,filter,-material-----------------------Total length.--------------------------- ------- ---- - ----------------•- Seepage Pit: Distance to nearest yrell�____Distan m fo ndation_/_Q_____----.Distance to nearest lot line__ _ [fes Number,-of pits ______________Lining material___ _ Size: Diameter__ '�1 f Cesspool: Distance from nearest well_----- ---------Distance from foundation,-------------------Lining material-____..__--____________._--______-_. ❑ Size: Diameter-------------------------- -----------Depth--------I # ----•--------------- ---------------Liquid Capacity- ---------------------- gals. Privy:, Distance from nearest well__,___________________ krr"' Distance from nearest building I11-: , g= --------------- ----------- ----------- ( , ❑' Dis#ante to nearest lot line. ---•------------- ----------------- Q\ Remodeling and/or repairing (describe)_------------------A-& A SEPTIC SERVICE . a - ------ ------------------------ - -- ------------------------------------------------------------. -------------...__. 9tf5 f:MieRv : #�5r-Calaf-------------- ------ ----------------------------- ••, r '_ - ------------------------------ ^_ �Howard 6-3M- --------q----•----------------•---------------------- ------------------------------------------------------------ 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 re ulations f the San'Jos wri Local Health District:1 (Signed)_ ---- --------- ------------ -------- � � ----� ��=-- ------- -r- - ,-- -- ------------------------ -:--- -----------•-------- - - ---- --- --{----n--e•-r---a--n--•/----r---C---o--n--t-ra--c- +or)By:------•------------------•--•--==----------- {Title)-(Plot plan, showingsize of lot, location of system in.relation to 41s, buildings, etc., can be placed on reverse side). 1 —FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - --- - -------------------- DATE---------------- �'� --- REVIEWED BY ------ ---- --- hi - ----- DATE------------- BUILDINGPERMIT ISSUED--_---------------- -- --- ------------------------------------•------------- DATE. Alterations and/or recommendations:--------- ------------------------------------------ ------ -• - -------•------------- ---------------•-----------•--------• �-v ------- F1NAL INSPECTION BY:- _ Date ' ` E SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Straat 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revisea 1.57 f.P.CO_