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APPLICATION FOR SANITATION PERMIT Permit No�3-/-�--/----- (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. 549. JOB ADDRESS AND LOCATION-_-- Owner's Name V/ fel!- (I ---------------------------------------------------- Phone-- IAddress-----------------------------------------------2119------ a....��1�-�J �.. Contractor's Name--------------------------- aas.p0�R14Ishl-' ISQl>7* t 1i --------------------- Phone-f! + 0,7 Installation will serve: Residence A artment House Commercial Trailer Court D Motel Other Number of living units: ---4 Number of bedrooms --jow--Number of baths I----- Lot size _-(O-p.....?�__.� e�f3-------------------- Wafer Supply: Public system ❑ Community system ❑ Private ❑ Depth to Water Table,310ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe in. Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ ra; TYPE OF INSTALLATION AND SPECIFICATIONS: w (No septic tank or cesspool permitted if public sgw r is availa�le ifhin 200 feet.) Septic Tank: Distance from nearest well-4-0-�_.Di `��'' p�l�yy �/� _ 4 pn� Distance from`faunf�ation---�__-__- -_.__.Materia -----------------. No. of compartments_-__,Z----------------Size ��JJ4!el�, �fiquid depth_-- -�f-______-_Capadty.. +lT_Q-.------- V..------..Distance from foundation--- -1 Disposal Field: Distance from nearest vel �-_----------Distance to nearest lot line-.67 01-.___ O Number of lines---------------- ;l--_------Length of each line-- Q-r-_-----�------Width of trench--,-z- Type of filter material-- -__R-k_-Depth of filter mate ---------_--.---Total length__-__A-$-------------------------- Seepage Pit: Distance to nearest well--,Q-,&...........Distance fro four ation-_—/0------___.Distance to nearest lot line------4--_-_-- ( Number of pits Lining material-ICA ize: Diameter.---'3 'f-f----.Depth--IAF-Q-~---------------- Cesspool: Distance from nearest well-__------------Distance from foundation--------------------Lining material-------_-__---__-_----___--_.---.__ ❑ Size: Diameter--------------------------------------Depth-----------------•----------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---------- ------------_------------- __-----Distance from nearest building------------------------------------------ F1 Distance to nearest iof line -,-/ RemodeI' g a /or repai in (describe): -_- - _I _..}�r4 -- �ra s �5� �.o�tc1�---------------- `-------------------- - ----9. ------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------•----------------------------------- 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)---- --� ----- - , -w_ -- --�ja ---------- *&-------w--------�Owner an /or Contractor]*- ----- - -- ----- -4--- ------- ---------------- -- - --------------------(Title) :. -� .7 -�l� (Plot plan, sho g size of lot, location of ystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY = DATE---------31,7jy ' °"`" REVIEWED BY----------------------------- - -------------------------------- DATE ------------------------------------------------------ - -- --------------------------------------- BUILDINGPERMIT ISSUED---------------------------------- --------------------------- DATE----- ------------ ---------------------- ------------ Alterations and/or recommendations-------------- ------------------------------------------------------------------------------------------------------------------------------------------------ ---------------------------------•---------------------•------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------- ------------------------•----------------------------------------- ------------------------------------------------ ------------------------------------------------------------ � , FINAL INSPECTION BY: 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