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APPLICATION FOR SANITATION PERMIT Per ..1� {Complete in Duplicate) / �! �( y t . Date Issued Applica4-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. JOB ADDRESS AND LOCATION'.1--- � -�---�=-3-------:---�-----�--�SIy-J - Owner's Name-- a ----- Phone--------------------- Address------------- —,A"- ---------------------------------------------------------------------•---------------------------------- --- ---•--- --•----- ----- Contractor s Name = f7 R►-. l�il ------ Phone Installation will serve: Residence [lr__A'partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other p Number of living units: __.__X,Number of bedrooms ---k Number of baths ----/-_ Lot size ----_ Water Supply: Public system R<Immunity •sy_ste-n_ ❑,,,Private ❑,Depth.-fo Wafer_ able --__---- ft- 1. Character of soil to a depth of ijeet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No g�-`New Construction: Yes Rg--No ❑ TYPE�OF INSTALLATION AND,SPECIFICATIONS: j (No septic tank or cesspool permit#ed'if public sewer is available within 200 feet.) Septic Tank: - Distance from nearest,well-----------------Distance from foundation-------------!. --.Material_---._------__---_..-----_ ----___---- ❑/ No. of compartments --------Size----= ==--------- ---'--'Liquid depth------------ Capacity disposal Field: Distance from nearest well_---.- t,---.._Distance from` foundat.ion--------------------Distance to nearest lot line----.------.----_ ❑,t 3j1S iN f Number of lines--------------f_--:---^:---__-Length of each line-----------------------'-----.Width of trench----------------- -------------- -a Type of filter material-------------- .-,-Depth of filter material------------.... ------Total length_--.---.--------.-----_------_----------- r' i Seepage Pit: . Distance to nearest well-,{ 13h/Y-'Dis+ante frprn foundation--c?-d--�-_-.Distance to nearest lot line- Q-----__-_ Number of pits- --- ------------Lining material--- --Size: Diameter----3 "_e._---Dept h.......47:J--l----------• �` I } Cesspool: Distance from nearest well------------- Distance fi`om�foundation...,-._.....- _-_.. Lining material-_.-----.-..---__.-.-_----:-._------. Q ElSize: Diameter Depth `-------------------- --------- -----Liquid Capacity--------------------------gals. `11 Privy: Distance from nearest well -------------------- -----------" _ _ _ _ -_., -__._. -- g Distance from;nearest building R ❑ Distance to nearest lot line_.---- ------------------- r Remodeling and/or repairing (describe):.............� f / ` �'T' / Cd1. ---------------------------------•---------------•-•------ ------------•---------------------------------- --i --- --- ------------ ------------------------------------- -------------------------------------- ----------------------------------------------- i ---------------------- •-----------------•----------------------------- ------------ - ---------------------------------•----•----------------------------------I I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State. s, and rules and regulations of the San Joaquin Local Health District.(Signed) - C---------------------------------- --------------- ------- --- her and r ontractBy:.--------- 0 o---- ------ - --------(Title)---- - - -(Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). I FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- - -------- --------------------------------------------- DATE----- --------------------------------------------------- •----•------ BY REVIEWED ER S - ------------------------------------------------------------ --.-.- DATE------ � ---------------------- ---------------------- BUILDING PERMIT ISSUED----------------------------- -------- DATE---.---------- -- ------------------------ --------------------- - y Alterations and/or recommendations: ---------------- � ---------•-------- --•----------------� t = - - - - - ---------------------------- - ----•----------- -- .- -. .. ------------------------------ FINAL-INSPECTION BY:------- - ------ Date------,,r ©--r-. ' �j SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30o West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California { Lodi, California Manteca, California Tracy, California E"-9 rasaas nrwaoo