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t -APPLICATION FOR SANITATION PERMIT Permit No. .. ..IV- Application ........ .... (Complete in Duplicate) Date Issued _, _ Y3 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 DOrdinance o;549. JOB ADDRESS AND LOCATION......r� _--`�_. -d�_-- - _- -- -•--------_ Owner's Name------- ----- ----- ---�--- ----- ` Phone-- ----------- Addressr- --- ----- ----------- --• ---------•- ------ -------- -----•------------------•--- Contractor's Name ---------...0 4 ------ ------------------ --------•--------------------------------•--- Phone-- l---.Q_ -A------6--- ------- -- Inst ---- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel p Other ❑ Number of living units: .__ Number of bedrooms Number of baths Z. Lot size ------- Wafer _---.SWater Supply: Public system Community system ❑ Private ❑ Depth to Water Table ___.a. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobex Hardpan ❑ Previous Application Made: Yes ❑ Nov New Construction: Yes)K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if pub lic sewer is available within 200 feet.) Septic Tank: Distance from nearest well____�7_d.1__Distan e from foundation_______S p aZ aj� �.---------.Mater------- ---- - --------M----- ------- No. of compartments------ �_ Liquid depth------"/6L__------Capacity__.--P4 d_ Disposal Field: Distance from nearest weli___�- e___.Distance from foundation___-R47!----- 'e -- p - � �^�_._____Distance to nearest lot line_�_______..�1 Number of lines_________ ____ / Length of each line_`-b-__3a'3�/-_s"�Width of trench.._ __ _��___._.______.. Type of filter material��aT 't-._ _ --Depth of filter material__118,-.___-----Total length___.--��-4-`------------------- 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------------------- material__._-___------_____________.__.______. ❑ Size: Diameter------------ - ---------------------Depth------ -------------------------- --- --------------Liquid Capacity----------- ---------------gals. Privy- Distance from nearest well______________________________________----.____Distance from nearest building.__---__.___.-_-_-_________--___.____._ ❑ Distance to nearest lot line----------------------- • Remodeling and/or repairing Idescribe)-------------------------------------------------------------------------------------------------- --•-----------------------..._-•------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- , 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)-------------- ---- -------------------------- - --------- --- (Ow r and/or Contrac 'r) By� ------ !- tsy7, erm, - ---- ----- - - -- ---------------------- --------------------- -------- --- -(Title)_ � - -- - - (Plot plan, showin size of lot, location 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------_V Alterations and/or recommendations-------------------------- -------------------- --------------------- -------------------- 0 ----------I----------------------------------------------------------------------------------------------------------------------------------------------------------•-------------••--------------------•------------------- ----------------------------------- ------------------------------------- ------------------------------------------------------------------------------------------------------------- -------------------------------- FINAL INSPECTION BY:........I/._... 7._- - 1 ----------------- Date-----------_I_.- -------------------------------------------------- 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 10-52 Revised W-2100