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APPLICATION FOR SANITATION PERM i Permit No. _______________ ____ (Complete in Duplicate) l Data 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. 67 _X3.0 —t 2- 3 1 S- E . Se c/,C_,aW Tr- r JOB ADDRESS AND LOCATION__//A_& I�__ Owner's Name------------------------------------A`✓ts-'-'-`-'tom.---ju-CI -fit- +3------------------------------------------------------ Phone---- _-_Y�'_51f7--------- Address----------------•------•-----------•------------14q( f Contractor's Name-----------------------------l Q .--- - s ? •e + Phone.. ` f Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other 54 i Number of living units: _ _ Number of bedrooms T Number of baths __ Lot size --- '__�___ .___�_��-_ ---_--___. Water Supply: Public system ❑ Community system '❑ Private JK Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ r Previous Application Made: Yes ❑ No New Construction: Yes A 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�r1)-�___Distance from„f undation__ Q -----_M�iai_-_�_______.__ No. of compartments--.:a_ __________________Size-0-6 ---Liquid depth- �'_____Ca acit Disposal Field: Distance from nearest well•,: _'_.Distance from foundation___ .__.Distance to nearest lot line _ Number of lines-------- ---Length o each line----- __ __"------------Width of trenc'n_ _r/,*' '_.-___- ) Type of filter material__f_ 'is_-_Depth of ter material-___/__ ------------Total length---------- �__`---------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---_--_-______, ❑ Number of pits----------------------Lining material-----------------------Size: Diameter------------------------Depth-------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation---------_---------.Lining material-------------------------------- ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------.Liquid Capacity-------------.-------------gall k i @ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------..--------.------- - ______.___7" ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------------------------------------•------ (.3 -r. Remodeling and/or repairing (describe):---------------- ------------------------------------------------------••--•--•--------•-•-•--•------------------ --------•----•---------------- - -•----•-•-----------------------•-------------------------•-------.....- ------------------------------- -----------•------ ----------------------------------------------------•-•--------------------- - : . ----------------------•---------------------------------------------------•----•-•---------------------------------•------------•----------------------------------------------------------------• ------------------------ a.,• I hereby certify that 14�ave prepared this application and that the work will be done in accordance with San Joaquin County I ! 1 ordinances, St e.laws, and rules and regulations of the San Joaquin Local Health District. - --_-• ,�,..,_. --------• - r Contractor (Signed)---------------"-- • --'---- - - - fx ��" 13 . �'�1 ---------------------------------------- Tifle - r ( ) (Plot plafi1:"s owing size of lot, locatien of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED B - ------ ------ ----- - --- - -"------ ----------------------------•---- DATE�"------------------------------------------------- 1 REVIEWED BY----------------- ------ ----- ---- --- --------- -------------- ------ -"- - ----------------------------------------- DATE "- BUILDING PERMIT ISSUED-______ ---------------------------------------- --------------------------------------- DATE -------- - ----- --- --- Alterations and/or recommendations---------- ---------------------- ---- --- ---- ---------------------------------------------------------- = ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:_ Xor,7------------ ._ 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-9-2M 8-51 Revised W-2100 f� I