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,4\aM A&CATION FOR SANITATION PERI• Permit No. ..._`�.._.-.:... <br /> (Complete in Duplicate) <br /> � Date Issued -.. ...3�5� <br /> N gplica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. <br /> This application is made in compliance with County Ordinance No. 549. ^� <br /> JOB ADDRESS A 1� LO�C,A{TION---I- a.y....... AR.,-'19O�S.AS ------*k. e----- 1<..+r <br /> Owner's Name....4✓ t 1y 1 t ..;- K-`. l-N_L.�`T1 - ... - ..........- - - "Phone .._.-........._.._.......... <br /> Address-----------........ - <br /> Contractor's Name ' ........... f}- -R.l`� - -�'md� .........................................'--•---'-..I....... Phone//Cl.'.tf� <br /> Installation will serve: Residence ❑ Apartment House ❑ Commercial k'l Trailer Court ❑ Motel ❑ Other ❑ <br /> Number of living units: .'1..... Number of bedrooms ../.... Number of baths 2.... Lot size -1-092 .....I----------------------- <br /> Water Supply: Public system ❑ Community system ❑ Private P Depth to Water Table .!VjS`ft. <br /> Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lk Hardpan ❑ <br /> Previous Application Made: Yes ❑ No 9 New Construction: Yes ❑ No <br /> TYPE OF INSTALLATION AND SPECIFICATIONS: <br /> (No septic tank or cesspool permitted if public sewer is available within 200 feet.) <br /> Septic Tank: Distance from nearest well.................Distance from foundation-....-....-.........Material................................................. W <br /> ❑ F-P01,v& No. of compartments.........................Size................................Liquid depth-----'-'' . --""..Capacity-----""--'--...... N <br /> Disposal Field: Distance from nearest well _Distance from foundation....................Distance to nearest lot line... <br /> ..------------ <br /> ❑EXfSfr G Number of lines...................................Length of each line......................-......Width of french............................. <br /> .-..-. <br /> Type of filter material-------------------------Depth of filter material.--..--�-/--f.............Total length........... <br /> Seepage Pit: Distance to nearest well-..1..2:40--.----Distance from foundation--..#al......Distance to nearest lot line..�0........ �• <br /> Number of pits---61N _.Lining material.?- &1'- ----Size: Diameter._.4e-"-_....Depth-_340...'.............._4:0 <br /> O <br /> Cesspool: Distance from nearest well.................Distance from foundation--------------------Lining material..............................-------I V' <br /> l <br /> ❑ Size: Diameter-----------------. ---"-.........Depth -"--"--'-'`............ . -----------Liquid Capacity--'--- '................gals. <br /> Privy: Distance from nearest well........................................:........Distance from nearest buildint------------------------------..-..------ <br /> ❑ Distance to nearest lot line------I---------------------------------------------------------.....------...._----.....---------------------------------'------ <br /> Remodeling and/or repairing (describe):..._.A.JC-_T//1.1. ............2',V............ G............DAV/.`14K5..E--..4474-q <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, State�a rules <br /> and regulations of the San Joaquin Local Health District. <br /> (Signed)--.------- .-.-. ..---r�:.�AI. . . .. --�t.l - -'-.---.'---- -.--.- -.---(Owner and/or Contractor) <br /> /��� ---------- <br /> By° -...-v --/'r-� ! ------ � -- - .... --'--- .....(Title)...... Ax <br /> _.......-------. . . <br /> (Plot plan, showing size of lot, location of system in relation } wells, buildings, etc., can be plat on reverse side). <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY.......... ... . ......... . - t C1-.r - Tt f DATE.... - <br /> REVIEWEDBY............. -' ..-............................. - - ................. DATE---------------'-.... - <br /> BUILDING PERMIT ISSUED---- .....................................................- ........................... DATE---.......-...............---............................... <br /> Alterations and/or recommendations:'•----' --...'--'-------'----------------------------------------'-'---'----"------'--------•-•----....------------•--•'-..................""........ <br /> -'-----'------""'-"'-"---'--"............................................................................................................. ----------'--'-'--'-'2t-..---...... ....................... <br /> --------- -......... ...... .................... <br /> ..... <br /> FINAL INSPECTION BY--------------v...-. .-- - Date..._ ...... . . . .... .............................. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 130 South American Street 300 West Oak Sfreet 132 Sycamore Street 814 North "C" Streef <br /> Stockton, California Lodi, California Manteca, California Tracy, California <br /> ES-9-2M I Revised W-2100 <br />