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APPLICATION FOR SANITATION PERMIT Permit No. .l (Complete in Duplicate) Date Issued ____, 71S 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 ------ �� K �Y -----------------------------------•------- -------.--------------- C hh�� j e, r Owner's Name-----------\)_Z. Phone tv_l` �1_ ` Phone-----•----�--------------------- Address---_--__----- _� t l G� ' 5�(1��z Contractor's Name iil� l�,,�� --------------------------------- -------------------------------------------------------------- Phone_--------------------------------- Installation will serve: Residence Wr Apartment-House❑ Commercial ❑ Trailer Court ❑ Motey ElOther E-1Number of living units: ---I--- Number of bedrooms ___(____ Number of baths ---- Lot Lot size ---- _ _______X_�4__�J ___._"_.__ ---------------------- Water Supply: Public system; Communitysystem ❑ .Private,❑ Depth to Water Table __ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe V/ Hardpan ❑ Previous Application Made: Yes ❑I No 4 New Construction: Yes ❑ No PHANA: Yes ❑ No d TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitteA p lic sewer is available within 200 feet.) rr Septi Tank: Distance from nearest w I______ --__Distance, from fouridation____�_Q_________.Ma efial___" No. of compartments-------�-------------Size-- xsx__C{__---:--_Liquid deipth------�---:----------- Capacity-_- -- -• Dispo I Field: DistancNumber of lines -1��'Ll�---LDength of ea h I ne foundation ________Distance to nearest lob line___ ___________ s _ _ ance from [J - i Width of french of filter material=�_ - _ ____=___Depth of filter mate ria l___-_1.�1____ ___Total length_______41 --------------------------- Pit: Distance to nearest w �'1c ___- Distance fro foundation___ r_`______Z ta �e to nearest l fine___�-_______f'Numberof pits-------I-------------Lining material______-Size: Diameter--- _±- --------.Depth-----s__-_______________------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material -_____-___________-____-__________-_El . Size: Diameter--r--------- --------De th----------------------------------------------------Liquid Capacity ----gals. Privy: Distance from nearest well_____ ___________________________________________Distance from nearest building__________-Y----------------------------- ❑ Distance to nearest I t line---------------------------------------- ------------------------- ------------------------------------------------------------------------- 1�. ---- Rem leling nd/ r i -ng (descri c -------- ----------------- ---- ---�--- ------- - ----- -------------------- -- ----- ------------------------------------------------------------------------------------------------------ ----------------------`---------------------------------------------------------------------- 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. (Signed] ---------- -------------------------------------------- ---�(OwnB -------------- t._k1i�L ----------------I-----------------------------------(Title]----------------- --------------------- Y 64(Plot plan, showing size of I , location of system in relation to wells, buildings, etc., can be placed on r FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__---•- I--= M-- --°---_- ---%- --------=-- DAT&= --------------- REVIEWED BY------------------------------------ I--- -- _ DATE----- j--- - &A_;:YA- BUILDING PERMIT ISSUED--------------j-------- ----------------------------- - ---`----------------------------- DATE-------i -------- - Alterations and/or recommendations=------- ------------------------------------------------------------------------------------------------- •------------"--------------•------------- ------ �2 s ---�-- -------5 -�-d........................... -- .,,,, . i . I -------------------------------------------------------------1--------------- ------------ 1 1 • w 11NAL INSPECTION BY: •---------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+reat 300 Wes+ Oak S+res+ 132 Sycamore Street 014 North "C" Stree+ Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revisea 1.57 F.P.CO.