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APPLICATION FOR SANITATION PERMIT Permit No ;�_6--- X1, (Complete in Duplicate) y.. r Dafie lssuec�y/�7/ A Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This ap lication�is made,,m. ompliance with County Ordinance No. 549. JOB'ADDRE55 AND'LOCATION_ •ak-.1"w_.y - s:. Ice�_f_ ,c ..___� ,�__. .a___ __ -_o�__ _QO Owner's Name-------------------------------`�a-ncy-------�StLI�(-/4 r ------------------------ - - - -------------------__ ------------- Phone_ -4-!-- - ------ -- -&--------••••-.--.-•-------------•---_..•---------------------------•--------------._....---- Contractor's Name----------------------------A--a -r•€---------------------------------------- �1` �j o ---------------------------------- Phone----- -•�=---�------ -----..._ Installation will serve: Residence-Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other I:15�1.5;&G Number of living units: -------- Number of bedrooms -------- Number of baths ----L_ Lot size _________________ Water Supply: Public system'K Community system ❑ Private ❑ Depth to Water Table _A4�? ft. 10-" Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe%, Hardpan ❑ Previous Application Made: Yes ❑ No 4 New Construction: Yes ❑ No ❑ + TYPE OF INSTALLATION AND SPECIFICATIONS: V_ (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptic T�nk:` Distance from nearest well_________________Distance from foundation--------------------Material----.-.-----.--.__.-_-__________-___--.__------. No. of compartments-------------------- -- Size------••------------------------Liquid depth---------------- --------Capacity-----------------------� osal ieW: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_---_-_-----_---. ""� dumber of fines-----------------------------------Length of each line------------------------------Width of trench.------------------------------_- Type of filter material--------------- Depth of filter material____-________________Total length------------------------------------------ Seer -_------------------- ------------------ Seep ge Pit: Distance to nearest+well,_s* �.-.-_-Distanc`e�,fr 4fofundation_ _ ________.Distance to nearest of iine----4____-_--_ Number of pits-------1--------------Lining material_ ___Size: Diameter-- sr ---Deptnr l _'------_--_---- __ Cesspool: Distance from nearest well-----------------Distance from foundation---____________---_Lining material----_-_-_____-__-__.-____---.-_____. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gal . Privy: Distance from nearest well-------------------------------------------rc_____Distance from nearest building----------------------------- __ - ❑ Distance to nearest fot line--------------------------------------------------------------- ------- -------------------------------------------------- -------------- Remodeling and/or repairing (describe)=---------------------- --------------------------------------.•------... ---------------------------------•--- ---.-1. ----------------------------•----------------------------------••-------------•-------------------------------•-----------------------------------------•---------------------------------------------------------------------` -----------------------------------------------------------.----------------------------------------------------------------------------------------------------------------------------------------.------------- r� ------------------------- --- --------------------------------------------------------------------------------.---------._______--_-_--__--------_--_---__-.-_---____-----_-.-----___-_--____-..---._-.-_--_-___________-_-._ I hereby cer fy that I ha a prepared this application and that the work will be done in accordance with San Joaquin County ordinances, at laws, a d� and regulations of the San Joaquin Local Health District. ` (Signed) C� Contractor By:------------------------------------------------------------------ ----- d, ---- --= (Title)-- ` [Plot plan, showing size of lot, location of system i relation to wells uIIdings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- -------------------- --T-----------\j-�)S---------------------------------- DATE---------- -------------------- REVIEWEDBY------------------------------------- -------------------- ----------------------------- ------------------- --------- DATE--------------- ----------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE------ ------•----------------------------------------------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------------------------------------------------•-----------•------------------------.-------•--------------••---------- ---------- -------------•----------•-------------------••-----------------------------------•-----•-------------------------•-•-----------•--- ----•------•--------------•--------------------- FINAL INSPECTION BY------- ------------ - -- - - F �-------.---------- 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 1 ES-9-2M 10-52 Revised W-2100