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APPLICATION FOR SANITATION PERMIT Permit No.-.... (Complete in Duplicate) ) . Date Issued 2xlp - 330 -`f2 Applica-�ion is hereby made to the San Joaquin Local Health District for a permit t construct and install the work here' des ibe This application is made in compliance ith County Ordinance No. 549. Az. j' xi x A JOB ADDRESS AN LOCATION.. ___ _.__._.__._ _---_-" - ""- "" c.r 0'-'�C Al �� r , --------------------------------�__.. ...------------------- Owner .--------------- Owner's Name-------------- a ---------- ------• ------ Phone --------------------------�..__..--------------- ---- - ---------- Address -----------------'•"-----------• — ----- �~I Y� ),,-& - e N ------- --------•---- ----------------- Contractor's / Name _ '. c�, ---- ---------��----------------- one----------------- ,Installation 7`1O - �C�✓ 1 Ph Installation will serve: Residence [}--'Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ `'t Number of living units: ..-*0'- Number of bedrooms _./_- Number of baths __/_- Lot size ____ ---•------------------ Water Supply: Public system ❑ Community system ❑ Privatej2--(?epth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sanclytoam EZ,-Cfay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No 9?"N--ew Construction: YesrS❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.)` Septic Ta Distance from nearest wells . Distance from foundation__.-�Q- "Material__-- ' p i, No. of compartments artments Size_ '� � Liquid depth_ '' Capacity- ` - � .� l Disposal Field: Distance from nearest well_� .�Distance tom foundation__ ___Q""�"..Distance to nearest lo} line______�C3""� L Number of lines----__/-- - --- Length of each line----- ---�------------Width of trench.---- -----��------------- � ��, Type of filter material .- ............ r____Depth of filter material_____.f�__- ::Total length--------------©.------------------ Seepage __""-_"__• _Seepage Pit: Distance to nearest well +:---------------Distance from foundation--------------------Distance to nearest lot line----------------- ElNumber of pits-----------------:.-!Lining material-----------------------Size: Diameter_ ------------ -----Depth------------------------------ N_ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material"___.______---_______._____._ `:� ❑ Size: Diameter. ------- -----------Depth------ -------------------------------- -Liquid Capacity gals. 1 Privy: Distance from nearest well__._._..." _._._____.._ ---------------------Distance from nearest building ❑ -------- Distance to nearest lot line----------------- Remodeling and/or repairing (describe):---.__"_-._____-- -----••----------------------•--------------------------------------------------------------------------------------•-------------------•--•---------------------------------•-------••----••-------------------------------- ( { i` --------------•-------------------------------•------•---------------•---------------------------•------------------------• ------------------•-------•-------------------------•------------------------------------------ 1 hereby certify that I have prepared this ap.2lication and that the wor ill be done in accordance with San Joaquin County ordinances, a laws, and rules and regul the an aquin L ealth District. X7 (Signed) �.. l Contractor) By:--------------------------------------------------------- --------------- i �J of plan. showing size of lot, location of system in lation to wells, b dings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 4 APPLICATION ACCEPTED B, --- ------------- ---------------- - --------- ---------- DATE - ------------------------ REVIEWED BY - - -- - -------- ----------------- ----------------------------------------------- --------- DATE- BUILDING PERMIT ISSUED--------- ------------------------------------------------------ ---- --------- DATE------0_r}.------------- Alterations and/or recommendations:---------------------------------- ----------------------- ------- ------------------------------------------------------...----•--•-------••-----------•---------•- .,. 'FINAL INSPECTIONBY:.. --------------------- ------------------- Date - SAN JOAQUIN LOCAL HEALTH DISTRICT IV 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street �* Sto'ek+on, California Lodi, California Manteca, California Tracy, California k E '3 745446 ATw"u"