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APPLICATION FOR SANITATION PERMIT Permit No. &_�............ (Complete in Duplicate) Date Issued l�/+�/�� 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•.--. _.._, _-_____-- - -------------�-=--- - --------------------• ----------------------•--------------------------• --• ------ Owner's Name ----------------V_ !�" d�---(AX-4.1-mss------- -----=- -------------------- -------------------- Phone---------------------------------- Address ----------- - ------ Address------------------------------------- ----- = ` } ----------------------------------------•- ----------------------------------------------------•--•.......... Contractor's Name----`------------------------ ----?=�=`-�'---------541,�-------------- -------------------------------------------- Phone.__ installation will serve: Residence 19 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: --.Number of bedrooms_.- Number of baths I-___ Lot size --he-_ _/_.,J""d"--------------------------- Water _____ ______-_Water Supply: Public system P9,'_Community system ❑ Private ❑ Depth to Water Table J.0 ft. 1 i Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑' Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe'N, Hardpan ❑ Previous Application Made: Yes ❑ No jtE�, New Construction: Yes X No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if-public sewer,is available within 200 feetr)"t Septic Tank: Distance from nearest we'll_ �j. Distance from foundation'_ �Vfr� I -�'�� -----•---.Material--------------- No. of compartments------ �___w__ � ; 1<iquid depth---7 �Capacity--- q- __.--__ Disposal Field: Distance from nearest weli_f . _Distance rom founda.t199_:'1_4-----.-.Distance to nearest lot line._____ Number of lines---__i_---_-_. Length of each line_______'4.� ._f_. Width of trench..._ __ ________ ____ W 'Type or filter material--_!-�y____!11----Depth of filter material------ '!_ Total_ length _ -_''__________________-.- Seepage Pit: Distance to nearest well_. ----Distance ro foundation ------Distance to nearest lot line_________________ Number of pits------ - ____-- - ------Lining materiaL _Size: Diameter___ -- Depth__ --------------------- Cesspool: Distance from nearest well------------------Distance from foundation-------------------.Lining material- -._..._.____----___-.---_.-._._ Size: Diameter- ------------- De th a - � _ ---------------------LiquidCapa,-c�y= - -- Privy: Distance from nearest well--- .__--Distance from nearest building------ ------------------- ❑ Distance to nearest lot lire----------------- Remodeling and/or repairing (describe)------------------------------------------------------------- N ••------------------------•------------------------------------------------------------------------- --------- -----------------------•-- ! hereby cert fy tha I hays prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State�aws d rules and regbiations of the San Joaquin Local Health District. (Signed) _O ne r and/or. Contractor) By: r sl[._�1�, (Title ' •-------------------•--------------------------• ----- ---� . _ - )-- (Plot plan, showing size of lot, location of system in rely i n to wells, buildings, etc., can be placed on reverse side). F FOR DEPARTMENT USE ONLY �� APPLICATION ACCEPTED BY----------- - -- ---. -------- --- -- -- ------------------------1----------- - DATa=---,/ ,------4l.----�'`="�-.-�------ BREVIEWED BY ------------- -----`---------------------------------------- DATE UILDING PERMIT ISSUED--------------•----- ---------------------------•-------------- ------ DATE- - -------------•----- Alterations and/or recommendations------------------------------------------ --- - ------------------------------------------------------------•-------------------------------••---------------- --------------------------------------------------------------------i----------•--------------------------------------------------------------------------------------- ----------------------------------------------------- ------------•----------------------------------------------------------------------------------------------------------------------------------------- --------------•------------------- ---- - --------- ------------------- ---------------------------------------------------- FINAL ------------- -- 1 f NAL INSPECTION BY:. - q_ _ -r Date --- --- ---------------------- -----_------------------- I SAN JOAQUIN LOCAL HEALTH DISTRICT II 1 . 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California � ES-9-2M 10.52 Revised W-2100