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AMF�ICATION FOR ,ANITATION PERWil' Permit No. ....Z_1 ... (Complete in Duplicate) 7s Date Issued ......--- 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. 2 2 3Gcla.en-_Gate JOBADDRESS AND LOC/CTION-------------- --�--------....... ------- - ------- - -------- -..........-----------•----------------------------------------- Owner's Name...------M2rr---COAtaCY20--•----------------........---------------- 5-D>9?-- ----------------------------- ----------- Address.---.............--F 2 e ----....------............--...........---......------.......--_-------- `x y j C Contractor's Name ...........Dalt&------- --------------- ----------_---------- .------------------------------------ PD, Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: ...... Number of bedrooms .2---- Number of baths _1____ Lot size ...J0---X---13A................................ Water Supply: Public system KI Community system ❑ Private ❑ Depth to Water Table__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam❑ Clay Loam ❑ Clay ❑ Adobe[ [ Hardpan ❑ Previous Application Made: Yes ❑ Nog] New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well.......... ------Distance from foundation....................Material--------------._....___------__...._.------------ e.y[�sting No. of compartments------ -------------------Size--------------..................Liquid depth--------------------------Capacity---------------------- Disposal Field: Distance from nearest well----------------Distance from foundation-------------.......Distance to nearest lot line................. extra ting Number of lines.........-_-------------------_Length of each line._......__.___.............Width of trench------------------------------ Type of filter material.._._...................Depth of filter material---------- __....._._Total length_...__.... _.._._......____ -------- Seepage ..._.--See a e Pit: Distance to nearest wellOistance from foundation...0.._.....Distance to nearest lot line..�.- -------- ...___. Number of pits-----I--------------Lining materlal.._bYICk-----Size: Diameter.....3.f.............Depth__._.--- Cesspool: �. Distance from nearest well_.._.-._..__.._Distance from foundst�on- ------_-------_.Lining material__._.__----------------_---_-._ ❑ Size: Diameter-- --------------------Dept h.---------------------------------------------------Liquid Capacity---------------------------gals. Privy: Distance from nearest well.................................................Distance from nearest building...----------------.._------------------ F1Distance to nearest lot line---------------------------------------------.........—....... ........ ............................................................ �+ Remodeling and/or repairing (describe):......._............... ---S. 3t1II.c�-_un:� C_ 3j5tr ................- ----------------•------------------------'--------------------------------------------------------...`----------------------------------------------------------------------- I hereby certify that I have prepared this application 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, (Signed)................_.._.... t-c.....__..--.--- - (Owner and/or Contractor) pPrr i;e.rtnexk " � By: (rifle) rla - �- - - ........- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on revere side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------------------------- ----- .... ... -..... ...... ............... .._. DATE;.__---•--------------_-_-- --- REVIEWEDBY------------------------------=-------`-----------------------------................................................... DATE-%;A.. BUILDING PERMIT ISSUED----------- ----- -------------------------.......................... ...... ......---..... DATE . - - - BUILDING and/or recommendations:-- ...... ---- --------.... --.... ---- ------------------..... ................C5-_"------c--......---------- ------ - - -------- - ; -- - - .............. ................................. - - ----- ---...............` - .....- - --- --- -- _ 1. ------ . ---------------------------- FINAL INSPECTION''BY:-- .. --- Date_.. - ------------------ - .--------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wesf Oak Street 132 Sycamore Street 814 North "C" Sfreot Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M - Revised W-2100