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sl� 9fs Q7 o APPLICATION FOR SANITATION PERMIT Permit No. ..7�d ---._ (Complete in Duplicate) Date Issued Applica+ion 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 ANCA ION__ //--------IM ---------14—_V6._'-..-- °.{f ---- 'Owner's Name--------KA�_ -------- ........... --i-SI 1.1 -RGC_Z_------ --- done Address__ ----------------•------------ g---- -�-�-x--'-- ==��-- -��a- - lam `` s_ ---------------- --------_ Contractor's Name-- '- -f------------------------------------- -------------- Phone -�7 -- 4----- , Installation will serve: Residence X Apartment House ❑� Commercial E] Trailer Court E] Motel E] Other Number of living units: A---- Number of bedrooms _.Y- Number of baths 1..... Lot size ____________._____.______ Water Supply: Public system K Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of sail to a depth of 3 feet: Sand Gravel ❑ Sandy Loam El Clay Loam [:] Clay E] Adobe E] Hardpan E]Previous Application Made:Made: Yes ❑ No A New Construction: Yes ❑ NoA TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)r _� ,r - (rte`? Septic Tank: Distance from nearest w•ell__,.�.�-_....Distance from foundation__Z--�P_---------- Material____ . _ `:�.�_________________________ Siz _ quid depth._��f._.._______ Capacity_�2,<-_6�� No. of compartments- ----------------- e -____a_ _ r_Li Disposal Field: Distance from nearesf_well..�4>�____Distance from foundation_w'V_____._Distance to nearest lot line_ r_f_____ Number of lines___.' ---T------------Length of each line__Lr�.__._--.--_____._.Width of trench_...�_-�--�................. Type of filter material___/ ---__5;1:----Depth of filter material-----1 --.-______.Total length______/�Q____________________________ Seepage Pit: Distance to nearest well-----__--------------Distance from foundation--------------------Distance to nearest lot line---_.---.--______ [] Number of pits----------------------Lining material----------------------.Size: Diameter-------•---------------Depth--------------------------------- Cesspool: Distance from nearest well-------_---------Distance from foundation....----------------Lining mdterial------------------------------------- 0 Size: Diameter--------------- ------Depth---------------------------------------------- -----Liquid Capacity----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building____-___---------------_____-------____- ❑ Distance to nearest lot line--------------------------------------------- ---•---------------------=--•--•----------------------------------------------------------- Remodeling and/or repairing (describe):_.- -- -------- � ---------------- ` �==----------'- C. _;� ---------------------- -------------------------------------------....------------------------------------- ------.----- ------.---------------------------- ----------- ----------------------------------------------------------------------•--------...------------------------------------------------.....-----.•-------------------------------------------------------------------------- I hereby certify that I have prepared ' plication and that the work will be done in accordance with San Joaquin County ordinances, State laws, n rules-and re atio s of the S 'Joaqu' LOC)BI-Health District. - ---(Owner and/or Contractor) (Signed)-------------------- - -`--- ----- ----- B ------_------------- a .......... «' -- - ---------------------(Title)---------------------------------------------------•------- (Plot plan, showing six o lot, location of system in relati n to we11s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- ------------------------ -------- ------ ----------------------------------------------- DATE_—---------------------------------------------------- REVIEWEDBY - ---------- --------------------------------- DATE-- ------------------------------------------------ BUILDINGPERMIT ISSUED----- -------- ----------------------------------------------•------------- .._.. DATE------- ---------- Alterationsand/or recommendations:--- ----------------------------- ------------ ------------------------------------------------------------------------------------------------------------ ----------I-------------------------------------------------- --------------- ------------------------ -------------------------------------------------------- ----- ----------------------------------------------------- ------------------- ----------------------------------- -- ------------------------------------------------- i J FINAL INSPECTION BY---------------- ------ 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 Ilylantece, California Tracy, California ES-19-2m 145446 ATWOO❑ 12-54