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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) a Y Date Issued ---3f 3!I-- -------- ______ 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. ,�f.504�_ C��nor;L-r%✓�-_�./� �� JOB ADDRESS AND LOCATION � -"�* I-�- - .1�-' " - ._ 'l� - Owner's Name:- 04 n Address----- D. 3 :.. x------- -- • A # i. Contractor s Name.. k ... - Phone -`---------- llj Installation will serve: ! Residence❑ . partment House [❑ Commercial ❑ Trailer Court Motel ` Number of living units ;1V 1.rNumber of bedrooms T � -- t�.-Number of baths __.__ Lot size ______._ Water Supply:}'P_ublic system'❑'-1- •omrr:u iify'systesn ❑ Pr_iva e� Depth to Water Table � r Character of'soil to a depth`of 3 feet: Sand [] "'Gravel ❑ Sandy Loam I] Clay Loam ❑ ,;.Clay ❑ Adobe, Hardpan ❑ Previous Application Mader Yes ❑ No New Constructi'on:' Yes No El ' /VA-.'Yes J_] s r v.. TYPE OF INSTALLATION AND SPECIFICATIONS ` ,--Lt (No septac tank or cesspool permit#ed if•,public sewer is available within 200 feet)_. F .fy� Septic Tank Distance JJfrom'nearest"well - Via_:___Distance from foundafion_-_ __a-.______Mat ric}i __11 ._ __-__ _:______ __._. _- XN - , No. Disposal Field. Distance from:nearest well _Distance from foundation_10 _ 4Distance }o nearest lot line ------- Disposal of lines____°___ _ --- - Length of.each.line_____________� O______.Width•of french__.__i-./n------------------- Type-'of -- ___-_..__.____ .� ► l Type of filter materiaL__,5) )43:�&__L-Depth of filter material_-..._f' ------- _length__ ______ ___ ---------I---________°_- Seepage Pit Y`: Distancejo nearest well _________'_Distance from foundation--------------------Distance to nearest lot line................. ❑ ` l�limber of pits --- --°---------Lining material--------=- -------- --Size: Diameter--- ----- _-Depth--------------------------------- .7F` lI. Cesspool: Distance from nearest welL":�------------Disfance.from foundation .___________.......Lining material.-- '------------------------------- Size: _-_. - __._ -__.____.Size: Diameter -- Depth -_ --- - ------Liquid,Capacity---------- -- - - ---gals. Privy: " Disfance.from nearestwell_ __ ....___._Distance from nearest building------..___.'-._ I Distance-ryto nearest lot line_ _ . _ ' _ Remodeling and/or, re airing (describe): ___________ - + ! ti --------------------------------- - - ------ --- } --- --- --------------------------------L '-------- - ------- ------ --- ------- -----------------------------7-------------------- ------------------------ ---- 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 reuI tions of the San Joaquin Local Health District. Z I 5i ned $ [ 9 1�► - - �L fGS� i`-Y (Owner and/or Contractor) ` ---`- . w ------------ -- -----} ------------ - •- -------------------- --------------------=---------------- • ` [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------------=------------------------------------------------------------------------------ DATE____------------ -- ----- ` --- ------- REVIEWED BY---:------•-w----'----------`.. ------ ---- ------------------- DATE = �= BUILDING PERMIT ISSUED-------=---------------- -- - = _ _ DATE --- = Alterations and/or recommendations: = '... - --------------------------•-,--------------' ------=------------------------- -- ------------ ---------- -- ----------------------- - -----.----- _---- ---------------------------------------- ----------------------------- -------•-•-• ------------ ------------------------------------------ ------------------------------___--- --------------- -------- ----•----------------•----------•-•----------•-------------=----- ----------- --------------------- ------------------------------•---•------------------•------------------- - r ,_ i - _ .., f . •' " FINAL INSPECTION BY:.- ,-'. ----`-- •---:-------------------------- --------- Date Date------------- ------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P.CO. --. —