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i I APPLICATION FOR SANITATION PERMIT Permit No.'- /y.- ; (Complete in Duplicate) Date issue 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 LOCA IIONf.�' ; Z4_477--- ---_'Z_------------------------------------ Own%er s Name --- --- �"~`` cam ' v�------- ----- -------------------------- - - Phone Address `... ...... ------------------------------------------------------ ••--------------------------------------- Contractor's Name ---------------- -------------------- Phone-- y— Installation will serve: Residence -Apartment House E] Commercial E] Trailer Court 0 Motel ElOther ❑ 1, :Number of living units:11 J____ Number of bedrooms ----__._ Number of baths ___1___ Lot size ------ w � _______________ Water Supply: Public system El Community system ❑ Private 4�epth to Water Table -------- ft. Character of soil to a depth of 3 feet: SancIAGravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ jM. Previous Application Made: Yb's ❑ No EA—New Construction: Yes [I No ^ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance f�k� m nearest well___ r ri•i Distance fro foundation__.__ ____.___- --�--- -- q _ Material---�'e--------- = -------------- --------- No. of co partments--------------)— Size_s3---N'__!__X_ . Liquid depth------- --- ---------Capacity-- - - --------- Disposal Field: Distance from nearest well__4�;;-P__..-_.Distance from foundation___111--- ...Distance to nearest lot line___,,'3__G-I Number o-il lines-----------f------- Length of each line----___�_5:_--'--------.Width of trench-._-2-- ........................ Type of filter material--- _ --Depth of filter material___.__-_lam"`.Total length___-_-��F__ --_-----_. Seepage Pit: Distance to-nearest well_.__--______-_._.___Distance from foundation---------_____`"'Distance to nearest lot line.... ElNumber of ----------------------Lining material__-___.__ _ .-____._- Size: Diameter-----------------�'pits. - - - ---.Depth--- ------------------Cesspool• Distance fiillOm nearest well_________________Distance from-found0ion��.-_____-_-.-__-_-.Lining material__.__--________-_____.__________._ :. SizedDiameter - =---------- Depth----------- ----------- --------------------------Liquid Capacity----•------------ gaPriv tyDistance turn nearest well---___.---______________________________________Distance from nearest building___---____.__._-__,----___- dl ----- ------- Distance tomearest lot line IIII -------------------------------- ------ Remodeling and/or repairing ( escribe)__________________________________ --••--•--------------------------------------- ---------------------------------------- --- 01 3� ----------------------------------------------•----------------------•------------------------------------------------------------------------------------------------------•--------------------------------•- ------------- I hereby certify that I hav prepared.Ais,application and that the work,will be done in accordance with Sane Joaquin County ordinances, State laws, and ruleI s and regulations of the-Sen JoaquinLocal Health District;" . . (5igned)_ ed LContractor) ---° y.... -------------------------------------------------------------------------Tale-- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 11U FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------- DATE------------- 1 --------- ------------------------------------------------ REVIEWED BY-----------------------------IG -- - ------------------------------------- DATE---------------------------------------------------- BUILDING PERMIT ISSUED------ ----------------- --------------------------------------------------------- DATE.--------------•-------- - --------------------------------- Alterations and/or recommends:lions----------------_---------_ --__-___________-- 1I, q1 - ------------------------------------------------------ •------------------- ------------------------------------------------------------------------------------------------------- ----------------------------------- ---------------•-----------------------•--.......... -------•-------------- -------------------------- --------------- - -- FINAL INSPECTION BY:____ -. _ --- ------------------ ------------ Date. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oafs Street 132 Sycamore Street 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 10-52 Revised W-2100 _ E!