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APPLICATION FOR SANITATION PERMIT Permit No�_ - w (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. 54F9 . JOB ADDRESS AND LOCATI N. . --------------5r-d.- Owner's - -----C--.-Y-i---l-d---`-�------r-- ----------------------- ----------------------------------•--------- Name--- ---- ---- ------------- - ------------------------------------ Phone Address------------------��--U / = c 5 -------------- Contractor's Name_____ _ _C1_ _ _ (I - - �`J -1-- ------------------------ Phone- IP Lam. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: j__ Number of bedrooms Z_ Number of baths /-'-- Lot size ----- -_a___ - - -- ---------------------- Water Supply: Public system ❑ Comm unity system.,❑ ,Private U�--Depthao Water Table _______ ft, Character of soil to a depth of 3 feet: 3 Sand Gravel E] Sandy Loam E] Clay Loam E] Clay E] Adobe Hardpan ❑� w Previous Application Made: Yes ❑` No ew Construction:. Yes No ❑ i '� TYPE OF INSTALLATION AND SPECIFICATIONS: l ¢ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) E Septic k: Distance from nearest well--- ___�------Disfance.from.foundation Material____________________________________________ Y9--- -- - -- No. of compartments--- .-`•---- --------Size--- _ _ %' Liquid depth___„---------- ---Capacity_.- -(4-----= Disposal Ield: Distance from ne�rial. er well_.. ___ _�. _.Distance from foundation.. Distance to nearest lot line -------- DV Number of lines _ i --L ngfh of each fin; Width of trench___` -- --------------------------- Type of filter ma ____ __-Depth of filter materia#__ _ ___________Total length--_- � __-_--- _-_- Seepage Pit: Distance to nearest-well--------------_-------Distance from foundation--------------------Distance to nearest lot line_________________ ❑ Number of pits------- -------------Linifg material-----_---------------ISize: Diameter'------------------------Depth--------------------------------- Cesspool; Distance from nearest well----------------- from foundation---------------I___.Lining material_____________________ ---------------- ❑ Size: Diameter--------- ---------------------------Depi-h--- -4----------------------- ---Liquid Capacity----------------------------gals. Privy: Distance from nearest well------- ________Distance from nearest building -------- Distance to nearest lot line___ _ _ _ ; ------------------------------------------------------------------ ' r Remodeling and/or repairing {describe}:---- -----------------------------------------------------------•----------- ------------------------------------------•-------•------- -•---------------------- ----------------------------------------------------------•-- ------------•---------------------------.---- ------------------------------•------------------------ -- - -------------------------- f I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State aws, and rules and egulations of the San Joaquin cal Health District. (Signed)- r - -------- - (Ow and Contractor) By:----l� -------------------------- -- Title( ) Pot plan, showing size of lot, location of system in relation to wells, buildings, etc., can beiplaced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-Q_ _:REVIEWED _ ._ DATE_ ! '' 13Y ---------- DATE ------------------------------------ BUILDING PERMIT ISSUED---------------------- ---- - --------------------------------------- DATE---------- 0s`., Alterations and/or recommendations_______________________ 4 W----------------------------------------- ---------•--------------------- ------------------------------------------------------------------------------------ -----------•-•--------•----------------------------------------'----------------------- -------------------------------------------------------------------------------•--------------------------------------------•------- ----------------------------------------------------------------------•------ ----------- ---- =--------------------------- FINAL INSPECTION BY:--,-A--- - ----ors, . is �" �— `�r`x--- --- D ---- - ----- -------------- ate--------- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Sfock+on, California Lodi, California Manteca, California Tracy, California LS-9-2M 8-51 Revised W-2100 JJJ