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r1g APPLICATION FOR SANITATION PERMIT Permit N _l.7 \' (Complete in Duplicate) • Date Issue.�;�Z-��7A��y AppJication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work her described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION_...._____. , --------------- ----------- --------•-•-•-•• •-- .....................1 -----------------••--- Owner's Names . .. ' Address- .. - Phone..--�--•----- ------------------ ----•------•----•-•--•---....._ .................. Contractor's Name.......... -- .---•--•.-•.......................•----..............-----•--._..• .__..._........ ••....._••--...---_.. .-----•--•........... .......... -- - Installation will serve: Residence Apartment Hausa r] Commercial-""-•-•......................... -... •--•----•-• Phone.............. ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ...___.. Number of bedrooms .%3._ Number of baths __/_. Lot size ....3a c� — 1 Water Supply: Public system r-----•-- PP Y• Y ❑ Community system "'' Y ❑ PrivateA Depth to Water Table -__.____ ft. 7 f . Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay❑ AdobejK Hardpan ElPrevious Application Made: Yes ❑ No 9 New Construction. Yeso No [] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permi#ed if public sewer is available within 200 feet.) s Sept c Tank- Distance from nearest well d___..."Distant from foun tion.._- _/) y .I.C/_.....___.Miteri J-- •--- No. of compartments...----- ....-__•SizeK �t iquid depth_...•------------ e -- �� _capacity-----. ..-•------- os I I /O[ . •. •--••• . --•-• D f r R Field: Distance from nearest well_. Q.-.----.Distance from oundatlon...1 -__.____-pis#ante to nearest lot fine__... _._..__- Number of linas_..�2_-_�_7�'+..�:�,_-"Len9#h of each line------------------------ -_."!"� 0 '� Type of filter material_ ' ._yy.��__._�, • ' -----1 1-1- Width. entrench..---- �----------------- Seepage Pit: Distance to nearest well----_----------------Distance from foundation....................Distance to nearest[of line_.......... p � ❑ Number of pits.------•---•----••.-" Lining material ............Size: Diameter----•--•--•----•----...Depth -- N Cesspool: Distance from nearest wall..... Distance from foundation...._..._-._ Q ❑ Size: Diameter......................................Depth_-.---•---•---- -----...Lining material...........................__•--... W --•--...------.......Liquid Capatify-•-••----•-.---- Priv : gals. Y Distance from nearest well Distance to nearest lot line..................................... ..........Distance from nearest building g••----••••-•-"--...---•....................... ' -. _. -------•"............................. ----••------•- Remodeling and/or repairing (describe):----.,, „- I --•-•----••-•- -----------------••--•-----•-••----...__....--- ..._..........__.....------------------------------------------•----•.........--•-••---•---- --•----- ..................... I hereby certify that I have prepared this application and that the work will be done in accordance with ordinances, State laws, an4 rules and regulations of the San Joaquin Local Health District, San Joaquin County (Signed]- - � �• � -(Owner and/or Contractor) BY: (Title].....-............................ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side- FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------go_ DAT ------ �. REVIEWED BY.................. ................ BUILDINGPERMIT ISSUED -------------------------------------------------------------------.....--•-----•--•---•..__._-..-•-•-----..c..------••--------... DATE................................... Alterations and/or recommendations:..__1/. -�• .� �� DATE_._ _"__•- �.n a � 1/ - •--•-•---•- -- - 1_ fz17...1�_zal�_.fet_�..---•-.. 'T.d`�.,7' .---•- •t'!rl�r '... ----• �_.__. + ......1. ........CP rs- Ail1 VA ._ -------•----- --------•---- --. -- ---'• FINAL INSPECTION BY:--.--...... ..... -------------I----------------- Date s SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak S+reef 132 Sycamore Street 014 North "C"Street Staek+on, Cel;fornia Lodi, California Manteca, Gelifornie Tracy, Calffornia ES-9-2M 8-51 Rev;snd W-2100