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APPLICATION FOR SANITATION PERMIT Permit No. __ d__5=-lei �. (Complete in Duplicate) 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- , JOB ADDRESS AND LOCATION I-_l F�,II X..... ----------A---------=------------------- W f� Owner's Name L -•------ y Phoned-. _': _ Address-•-3� � -1 _ :'c;: .. 1= ---------- --------------------------------•-------------•--------•-----------------------------•-------------------- Contractor's Name------------ �Wef 4'f"---------------------••---------------------------------------------_----------------------------------------- Phone----------------------------------- Installation will serve: Residence x Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __L_- Number of bedrooms -1---- Number of baths ---I--- Lot size _` ----------------------------------- —Water 'SuppiyS" Public'system ❑Community systerti ❑4`Private "�D Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or cesspool permitted if pu6lic sewer is available within 200 feet.) Septic Tank: "I Distance from nearest well_,'_© _" Distance from foundation f�_____.Maten l_____ -____--__- No. of compartments--------------{�__ -----Size____-"fi t - ---Liquid depth----------- ----------Capacity--- C ' ---- ! Disposal Field: Distance from nearest well__:` LA_Y"Distance fro .�D___-Distance to nearest lot lin l 'A-- p m foundation_____ Number of lines___________ Length of each line_______ _ 3- --Width of trench_______ ---_, ---------------- Type of filter material___-_5epth of filter material--.--- _.________Total length________Q___------------------------- '"� l Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- 4 ❑ Number.of pits----------------------Lining material----------------------Size: Diameter---.-------------------Depth--------------------------------- ' Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth--------------------------•-----------------------•Liquid Capacity---------------------------- - " Distance'from-nearest well-- ____ ______ ______ _Distance fnom—Tn' arest-building " ___: :------___:.--------- --. 1 ❑ Distance.!to nearest lot line_______ _________.___._ Remodelingand/or repairing (describe)----------- -----------------------------------------------------------------•------------•-----•------------- ------••--------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------•---------------•- , -•------------------------------------------------------------------ ----------------- ----------------------------------------------------------------------------------------------------- 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. 1?1 [Signed) `"` 1I --------- --------------------------------------- ----------------------------------------------(Owner and/or Contractor BY=---------- -------- --- --------------------------------------------------------------=Tit!p ---------------------------------------- -- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be laced on reverse side), ==FOVRTM=ENT USE ONLYAPPLICATION ACCEPTED''8Y ______ _ DATE»________-_---- ---- ----- - = v-- - BUILDINGPERMIT ISSUED--------------------------------- •------------------------------------------- --------------------- DATE--------------------------- ` Alterations and/or recommendations------------------------------------------------------------------ --------------------------------------------------------------------------------------- . r ------------------------------------------------------ --------------- -------------------------------------------------------------------------------------------------------------------------- --------------- ----------------f ----- -------- -------------- ----------------- ------------------------------------------------------------------ " FINAL INSPECTION BY:'----------------------- --•-- -Z------------------ Date----------- ----- --------------------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reel 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California _ ES-9-2M 8-51 Revised W-2100 b