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APPLICATION FOR SANITATION PERMIT Permit No. ,}y I (Complete in Duplicate) � Date Issued -1-I�-.-m......r. 6)eS'_ 3aa -3z- 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...................Z{51-( ._ ...-------.�t`�........... A9_ ....__. t — ...5_ OwnersName......... - " ---••-------••-------------------------------------------------------------------- Phone-------,�.r1- •. Address-----------*-- ............................... Contractor's Name--------------------•----•--•-----_--\:---.... Phgne -- ---------------- Installation will serve: Residence ® Apartment House C] Commercial Trailer Court El Mo Other ❑ ` Number of living units: -4-_- Number of bedrooms _._1- Number of baths ...!_ Lot size ___...... h..._ --: Water Supply: Public system ❑ Community system F] Private , Depth to Water Table _ �_ ft., 4.Y e l z Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Ye No New Construction: Yes No TYPE OF INSTALLATION AND ECIFIC'ATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)_. Septic Tank: Distance from nearest weII1M_.4"*__-Distancq from foundation..).�_-'__....__.Ma feria)__ --_•_-_---- No. of compartments---------fi _...-... e .. � �Liquid depth--*_!.r- -----------Capacity-4440-.---- _ � n�X m4Disposal Field: Distance from neest well-� Distarfo�dafion__-/J0___'_.....Distance to nearest lot ie4.....•._..Number of lines__ ... -------------------------- oeach line__--W ,...r--_______.Width of trench___ I Type of filter rnateriall...... l �_.......Depth oof�ter material...I!�----- --------Total length ;, -._•-._'_ - 6---__ Seepage Pit:- ,: Distance;to,nearest wall:f:' pistanee 'TM +#aUn anonDistance-to iearestlof Umber' o '" its. m6-terra .�� Nbmber�oT its. Linin material....__�Ssze: Tarter-- Cesspool: Distance from nearest well----------- ......Distancelf 6m foundation_,,.._-_-_____--__..Lining material-___..______._..--__________. ._ ._. ❑ Size: Diameter......... ..................... --Depth.----......................------.---_-----•---_-Liquid Capacity----••-------------------.gals. Privy: Distance from nearest well----------- --------------------------------Distance from nearest building --_-_-� ❑ Distance to nearest lot Nne------------------ ndel'ng and/ar yepairing (describe): _^ = -•= _________________ ___-_--�-- .---_y_-...___..__._.. ._. - ---------------- r b. A. __.�.- , I I hereby certify that 1 have prepared this a lication 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. • f (Signed)..._ . . '"f, f�r. . ............I-------------------------------------------------------------------- --------------(Owner and/or Contractor IBy:.... _ -----------------•----------•-•--------------- ----------------------- (Ti+le).. r� �.-•................ . ...•. (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side): l� FOR DEPARTMENT USE ONLY i ! APPLICATION ACCEPTED BY-.---•-•-------- - ------ DATE------_t_ __--__-• "` " 1 EViEWEb BY--------•-••---------------------------- -. -• -• --- ...---..-...----- --------- --------...-------- aATE_./._'.'f •----�"..._ - - ---• PERMITISSUED.... -_----------••-----•-----------------------•-•-------------•------ --------• DATE------•-•------------.._.. Altera+ions and/or rocommendations:_..--------------------------------------------- S ---•---------------------I-----•-••--------------------------------------------------------------------------- ------------------------------------------.--------------------.-----------•--•------ ...........................•---------- --------........ --........ __----------•1---------- ----.--------......---_...._.. FINAL INSPECTION BY--------------•- S/ V_1-�----------. Date----- a ./ I, SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 Wast Oak Street (32 Sycamore Street 814 North "C•' Street Stockfon, California Lodi, California Manteca, CaPfarnfa Tracy, California k ES-9•-2M B-51 Revised W-2100 f