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' E APPLICATION FOR SANITATION PERMIT Permit 3 Y Vej3 Nom l -- ` � (Complete in Duplicate) ! Date Issue -- r r 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--- L -. __- . ..•�.- '1 ------------------------------------ -------------- I Owner's Name--------------•--- --�}•a....c.?---------------•--- ------ f - ------------------------------- ------------------------- Phone__, 'f-7 / Address---------------•---------- ---------L --- - _ Contractor's Name -+ E --------------------------- ------------------------------ Phone Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __-�-- Number of bedrooms -I--- Number of baths -1-_-_ Lot size ------7e?--X ------------------------------------ Wafer Supply: Public system 2--c-ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [A---Hardpan ❑� Previous Application Made: Yes [-] No [ New Construction: Yes �o 04 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Distance from nearest well-- ___Distance from foundation-_-LD__ No, of com �_____-Material__--�_ -__ - - _ _ compartments - - - -------- p �. Size 1y d Liquid depth---- Capacity---------4 Disposal Field: Distance from nearest well- {-.-.Distance from foundation-40 ------------Distance to nearest lot line_- -S____,____ r Number of lines---------1-------- Length of each line---!� _Q Width of trench.----9_`�_.`----- i------- IF- Type of filter material---- ---------- -"--- --Depth of filter maferial---1 --------------Total length------------------------------------------ Seepage Pit: Distance to nearest well _________ Distance from foundation--------------------Distance to nearest lot line--____---_-- ❑ Number of pifs----------------------Lining material-------_---------------Size: Diameter-----------------------Depth--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------------_-_ ❑ Size. Diameter--------------------------- ----------Depth--------------------------------------- ---------Liquid Capacity----------------------------gals. 1 Privy: Distance from nearest well-___--____----- ----------_______--___---_-----Distance from nearest building - ❑ Distance to nearest lot line________________________.-_�____--_-__-_ - -_-- Remodeling and/or repairing (describe)-------------__-____. --- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have.preppared this application and That the work will be done in accordance with San Joaquin County ordinances, State laws, and rules_aW.regulatio�s of the San Joaquin Local Health District. (Signed)_-- ______ __ _____ T _ a�Y-t y_ -- ---r_r4,, - �- __{Owner and/or Contractor) By- ---------------------------------------------------------------------------------------------------------------------------(Tifle)-- _ __________ ______ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., canbe placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------ �'�-------`' ---------------------- REVIEWED BY a DATE ---------------------------------------- /�` --- DATE ,� L BUILDING PERMIT ISSUED_____________�l �' / ' f `(,f T ' ` ---- - ------ _ - _ iv Alterations and/or recommendations:_ -- E ------------------------------------------- ---- ---------------------------------------------•-----•----•----•--•---------------------------- _--------- f •x 1.' - �* nt.�rZ { - ,, ------ ,i -------- - ! �=_ � " - - n --------------- , - --- ---- � - _ r ------------------------------------------------- FINAL INSPECTION BY:-----------i.... -------------------- Date `f , 7 SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sfree+ 814 North "C" Street Stock+on, Californiaf Lodi, California Manteca, California Tracy, California ' FS-9-2M 8.51 Revised W-2100