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1 L"J�f3 v APPLICATION FOR SANITATION PERMIT Permit No' ...................... (Complete in Duplicate) Date issued o ..___ ��1� Appiica{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. 0S2�7—t 2-0 -..S3 `y/� JOB ADDRESS AND ATION._Ql f C`�'p ......Z 4� ---"_� -4.0� h_67--- A/V4�'-- Owner*s -------- Name..---- •------- -�-j_[..�- f /-------------------- Phone- '_ - Address_------------------------- '-----�1� l-.�-�7 --------------S_7-�..0-1�5��1�=-... ��------------------- ------------- ----------�------- Contractor's Name--. -- ._ f /..r ( �- '-----------------------------•------------------------------------------------ Phone-- ... f c. Installation will serve: Residence-E] Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other,K&I-Y t/s Number of living units: -----_ Number of bedrooms - Number of baths _- Lot size ---------------------------__-._ Wafer Supply: Public system ❑ Community system ❑ Private & Depth to Water Table M,-ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay-[] Adobe Hardpan ❑ Previous Application Made: Yes ❑ No K New Construction. Yes K No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) jo �( — 1 Septic Tank: Distance from nearest welf_- ., �__-Distance from foundation__ .---__--.Material_.-4+'�t�' ---- -- ------------- G, KNo. of compartments---�-_--------------Sizef _ !_��--Liquid depth---, �--.---------Capacity-- _Q---.+6rl1: r Disposal Field: Distance from nearest well--- from foundation_-/4 Distance to nearest lot line./Z01 r---_- rn Number of lines 67'"R .��-----------Length of each line____-�D-a ---------Width of trench.x�!t-__---_----_---__---- , Type of filter material/y��R�CK--.---Depth of filter material----�_p-------------Total length-_-.--SO-1 Pit: Distance to nearest well---4? ...........Distance from foundation__,15.........Distnce to nearest lot line----------------- j,3!1 Number of pits.---P ---------Lining material- i----.Size: Diameter- -----------Depth---.A,, ________------------. Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material------------------------------------- 0 Size: Diameter--------------------------- ---------Depth---- - ---------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well --.------ --------------------------------------Distance from nearest building--------------------------------------- ❑ Distance to nearest lotline----------------------------------------------- -----------------------•---------------------------------------------------------------- ----- Remodeling and/or repairing (describe):---- ----•----------•-------- . �_��_-- ----------------------- t� ------------------A.---------••-----------_--_-_ -----------_ _.--- -_-_ -_-__- •---_----•_- ••----___--- ..-._..-_--__-___-.-.-.-..__--- ----- --- - ----------------- . - -------G / °{ In I hereby certify Lha a~e prepared this application and that the work will be done in accordance with San Jo qui ounty ordinances, State laws, a d les and regulati,dns of the San Joaquin Local Health District. (Signed)---------------------------------- - --- ------ -- ---- =t -—----- -------------------------•- -(Owner and/or Contractor) By:_................ � ��------U � a -----(Title)------ -- ��-�------------------------------- owin size of lot, location of system in relatio .oto wells, buildings, etc., can be plat dfon reverse side). (Plot plan, showing Y ,r rt FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE -------- REVIEWEDBY------------------------------------------- ----------------------------- ------------------------------------------------- DATE---------------------------------------- .................. BUILDINGPERMIT ISSUED------------------------------------------------------------------------- --------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations-------- ------- --------------------------------------------------------------------------------- ----------------------------------------------------------- -------------------------------------------------------------- ------------------------------------------------------------------------------------------•-------------------------------------------------------------.... ------------------------- ------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ------------/ . -------------------------------- -----------------3--- -----------------------------------I-----------------._.._. FINALINSPECTION 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 Manteca, California Tracy, California r ES-9-2 M Revised W-2100 /