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I! APPLICATION FOR SANITATION PERMITPermit / *J�d i �P. 7. NO. li (Complete in Duplicate) / � - - -. -Date Issued _(�_ _77yS/ 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 ccimpliance with County Ordinance No. 549. --- --- _ r JOB ADDRESS AND L .CATION___. CSYU Owner's Name � ' L:" .r.-------- _ --------• ---------•--- Phone--=------•------ ,._. Address ___-_.----- - - ---------- ---- -- Contractor's Name--------- __- ___.___ _:__ -------------- ------------ .._------------------------------ Phone..-------------•------_-- Installation will serve: €Residence Apartment House ❑ Commercial Trailer Court r, ❑ ❑ Motel ❑ Other ❑ 'Number of living units:lij.___- Number of bedrooms ! Number of baths __/-__ Lot size'_____P��Az __ • . - -- --- Wafer Supply: Public system❑ Community system ❑' Private Depth' to Water Table _____.-_ " Character of soilto a depth of 3 feet: Sand ❑ Gravel ❑: 'Sandy Loam ❑ Cay Loam`s Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: �* (No septic tank or cesspool permitted if public sewer is available within 200 feet.) r Septic.Tank: Distance from nearest-well ____ Distancejrom,.foundation--_� � �,,. -------Mater•al--.- �: --- r No. of tornpartments---------9---- (--5-.Liquid depth_ ' '� j Capacity -�. Disposal Field: Distance fr`'pm nearest well----4-0-L-Distance from foundatio ------1_0___--.Distance to nearest lot line___ __- Number of6.lines--------j___-_ _ Length of each line_1__ C�__/_ Width of trench-----�--- ,. "' Type of filter material_ / tt �-Depth of filter .material--------- - __-__Total length......�___�j -------------- T"--0---------------••------ r Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line-______-______--_ ❑ Number oft pits----------------------Lining material-----------------------Size: Diameter---- -----.Depth------------ r ._ Cesspool: Distance from nearest well--------------___Distance from foundation_____------ -------Lining material--------------------------------------- ,.I].. _. Size: Diameter Depth ----------------------�._ Liquid _Capacity _ -: gals._ T _ _ - - Privy: Distance from nearest well------------------------- ___--.-Distance from nearest building 9 P --------- ------------ ❑ Distance to nearest lot line-------- ------------- -- f t ------------•------------------------------------------------------ g t :...� Remodelin and/or re pa iring fdescribe):-- -----� `- r �-•-------•-•-------•------------------•-----------------•----------------•--------••--••---•------...--------•- � --- ---------- ----- l` •--------- -------------•-------------------------------------•------------------------------------------------------------------•------------•-----------------•------------------------------------•-------------------------------- -------------------------I----------------------- -----------------•------------------------------•---------------.•.----------------------------•----------------------•---------------•-------------------------'--------- 1 I hereby certify that I have'prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law's, and rules and regulations of the San Joaquin Local Health District. (Signed). ----- ��-----I -' ------- --- ------- ner and/or Contractor) � By:------------------------------------!------------------------------ ----------------------------•-----------------=-------------- 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 BYj------•----------------- '--- ------------- --- DATE REVIEWEDBY---------------------------�------------------------- . ------ DATE---------- � � ---------------------------------- BUILDING � PI=RMIT ISSUED -1 ----- ---------- - ----1. _.. - --- - DATE Alterations and/or recommendations:_-_-__-__._ __---"______________ - - .. -------•------------------------------- - ------ -------------- ------------------------------------------ --------------------------•- ---- 1------------------- ----------•-----------------------•-----------------=------------- ------------------------------------------------------- ---- -------------------------------------------------- -- -------------- ------------ -- FINAL INSPECTION BY:....... "" ------ ------------------------ II ---.----- Date--- --------- -------------- SAN 'SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street j� 300 West Oak Street 132 Sycamore Street 814 North '•C" Sfreef Stockton, California l Lodi, California Manteca, California Tracy, California ES-9-2M . Revised W-2100 II