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APPLICATION FOR SANITATION PERMIT Permit No��.. ----------- (Complete in Duplicate)' ' '"w Date Issued/k, ------1�-lam___- ` Appliceion is hereby made to the San Joaquin Local Health District for a permit to construct nd install the work herein described. This application is made in compliance with County Ordinance No. 549 JOB ADDRESS AND LO ATION------- U -------sr` = ----- Owner's Name------- •----- ------------------------------------------------------ ------ Phon •------- -- -- --- a�6 --------------------------------------- € _ m. Address-------------------------- ------------------------ ---------•-----• ----•-=-----•--- - •--------------------•-•---•---------------------------•----- ' �x; 6/ Contractor's Name------- t--.`.. = - Phone _.... Installation will serve: Residence �Apartment,House ❑---•Commercial.[]...Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __(--__ Number of bedrooms _ Number of baths _ ___ Lot size . __' :__-____._ ------------------ 5 Y Water Supply: Public system E] Comm unity system ❑ Private ®depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ Adobe 23/Hardpan ❑ Previous Application Made: Yes ❑ No D New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted.if-public.sewer is availabie,within.200 feet.) 4Pt'. nk: Distance from nearest well-----------------Distance from foundation___________________Material-________________..._-____________---_--_____. No. of compartments---- -='------=`-----Size.--------------------------------Liquid depth----------------- -------Capacity------------- --------- Disposal ield: %- Distance from nearest well,.----------------Distance Distance from foundation---A_d---------Distance to nearest lot line._4�!_______ Number of fines___ ______________________Length`of each line____ . -Q.-____.____.Width of trench____ _` ---------------------- ------ _ . �r Type of filter material-_ 'r_ft'lZ_G .--Depth of filter material____._.✓-.._______Total length_____ ___ _Q________________________ .ir. •-. _ - ...r-.F Seepage Pit: Distance to nearest well ------------------- from foundation___-________..____..Distance to nearest lot ine________________ ❑ Number of pits-------�-------------Lining material------------------ _--.Size: Diameter-----------------------Depth--------------------------------- Number Cesspool: Distance from nearest well-----------------Distance from foundation -------------------Lining material______________-_.______ _ ____. F1 Size: Diameter-•---------- --------------- ---------Depth---------------------------------------------------Liquid Capacity ---------------- ... gals. Privy: Distance from nearest well----=--------------------------------------------Distance from nearest building----------.------------------------------- ❑ Distance to nearest lot line.'__" '=------------------------ -- I - �. a � Remodeling and/or repairing (describe) = = --------------------------•---•------•------------- -------•--•--------•---- i ----- ---------•-------- -------------------------------------- -- •-------------- `_...-----------•--------------------------•------ -- --• ----- ----•-•-------••-•- Z�_ -------- -•-- ----------------------------------- --------------------------••------------•-•------------------------------------- ------------------------------------------------------. ----------- ------ I hereby certify that I have preparecl.thisl�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)----T-O-Z-7 1 - -44, e! l--T------- ----------'................- (O Fier and/or Contractor) Ely:---------- �-P -- --------------------------------------------- ------(Title} [Plot }clan, showing size of lot, locaflo ,f of.system in relation to wells, buildings, a+c., can be placed on reverse side). FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY------------- ------------------------ ------------ DATE-------- y3 � - AREVIEWED BY--- ------------------- ------------------- --------------------- ----- ---------- -------------- ------ DTE--------� ---=------------------------------------ a BUILDINGPERMIT ISSUED--------------------------------------------------- ------------------------=-------------------=--- DATE------------------------------------------------------------ Alterationsand/or recominendations------------------------------------------------------------------------------------------------------------------------------------------•---------�.----- --- ---------------------- -------------- ---------------------------------------------------- ----- 3 FINAL INSPECTION BY----------------- `-•1/Z-------_- -- Date -------------------------------------------------- -SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak $treat 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100