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II p -- �. IE APPLICATION FOR SANITATION PERMIT �" Permit No. ____ _ _______ -- u (Complete in Duplicate) 4�. Date Issued ... ---------- Applica{ion is hereby made to the San J aquin Local Health District fora permit to construct and install the work herein described. This applicafion is made in compliance with ounty Ordinance No. 549. JOB ADDRESS ANDdLC)T ON_�D --- I__V�- _M -----��_fY,l �-- ��--•--------- Owner's Name----------- �t/� --------_ -- Q- - -�=----- .. _�7,t_7--- --------------------------------- ------- - - -------- Phone-----•-----...-•------ ----------- - - - Address...------_---------------- ----1-- - 0------ = _Ox 2 j� •--------- -- ------------------------......__-------- t Contractor's Nam ------- ---------------=------ -L am' `------------------------------ ------------------------------•-------- Phone -,l"4w_ 1 - Installation will serve: -Residence ❑ Apartment House ❑ Commercial X Trailer Court ❑ Motel ❑ Other t Number of living units: -------- Number of bedm roos - =_____._ Number of baths .---____ Lot.size ___ _________________________ Water Supply: Public°`syst rn ❑ Communify system ❑ Private 9 Depth to Water Table 15-- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay ❑ Adobe;` Hardpan [] Previous Application�Made Yes E] No g New Construction: Yes No E) TYPE OF INSTALLATIONIAND SPECIFICATIONS: f (No septic tank"or cesspool permitted if public sewer is available within 200 feet.) a Septic Tank: a Distance from nearesr well-,QQ`_____Distance from fou o at own___.'Q_______Material___ " ___________ _ _ ___-_.__ No. of compartments---- Size___ ©_ _______r__ Liquid depth___-- .f`___________Capacity_ 0O ___.____t �o �- --- Disposal Field: Distance from nearest well._-P-0..._:.D1stance from foundation___,2.2..._____.Distance to nearest lot I-ne___�_______ o .Numberi of lines__0___;�`_ _____rLengfh of each line__Z-APf r7._____._.Width of trench_.�_f______________ T e of filter material -1 O�o�°l{De th of filter materiaL_.��_-_-_:_____Total length___._.�Q jo_______________________ b � Yp � �'. - - p m. Seepage Pit: Distance to.nearest;well_.--. "_____________Distance from foundation ............._____.Distance to nearest lot line__--_--_--------- ❑ Number of,pits----------------------Lining material-----------------------Size: Diameter-------- -----Depth--------------------------------_OF :, Cesspool: Distance from nearest wel----------------- Distance from foundation--- - -.-..-,Lining material-------------------------------------- 171 Size:.Diameter--------------------------------------=Depth r-1--71--- --- ----------------------"Liquid CapacifY- --•------------------------gals. IV Privy: Distance from nearest well______________ __---____�_�~-._°_________Distance from nearest building_--------____________________---________- ❑ u .... .Distance to nearest,lot,line......------------y------------------------------ -----• ---=- . .---- Remodeling and/or re' g (describe]:- -- -- - ----- -- ------------------- ----- = ••----.•----- ------ ----•- --------------------------- ---------------------------- ------........•-•-------------- - o � 6 --- - :i -------------------------------------------------- •---------------- I hereby certify that I•have5pried this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andrruegulations of the n Joaquin Local Health District. ,A � � [Signed) ............--•--•------------ -------- �-' - ---- ---r--- ---------------------------------------------(Owner and/or Contractor` By:---------------------------------------- r ------------------- -•------------------------------------ (Plot plan,.showing-size of l'ot, location of system in relatio o wells, buildings, etc., can be plat on-reverse side).,:- - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED ___:__ DATE_ ----------- ________. 1.. BY_ ------ - REVIEWEDBY---------------------'-------- ------ ------------------------------------------------------------------------------------ DATE--- BUILDING PERMIT ISSUE6--------------��-`-�----------- - •---------------------� ------------------------------ ----- DATE ---�.. -------------- - -------------------------- Alterations and/or recommendations---------------------- I, -------•-----------------------•-------------------•------•--------=-- ------ ------------------ ----------- ----------•-•---•----------•----------------------------------•-••----------------------------------------------- ------------------------=---••-------- --------7---•------- ----------------- -=---------------=--------------------------------------------------------------------=-------- -----•------------------------------------- ---------------------------------- II; ------------------------------------- ---------- ----------------- -- -- - -- --------------------------------------------------- ------- - -------------------------------------- kt FINAL- INSPECTION BJ----- -------------- --•-----------i--�---------- -------. ---• Date-- = ----------------- I� 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 ES-9--2M Revised W-2100 � /