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# r APPLICATION FOR SANITATION PERMIT Permit No. t (Complete in Duplicate) Date Issued _____ Applica{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. JOBADDRESS AN LOCATION---., - ------ -------- ---- •- --- `--- ----------------------------i----------------------------------------------------------- ------- rRr Owner's Name-_ •------L_V_L----: ' Y Phone_ __.___-__-_.____ r. Address---------�_51- �--- - - ----- -------- ---------------------------•--•- Contractor's Name..- ------ ------- ---------------------------------------------------•--- Phone_,,'"-,....W/ Installation will serve: _Residence . Apartment•House} ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ r Number of living units: __l____ Number of-bedrooms _.F__ Number of baths __/, Lot size --------- ----X_!-4_b---------_______-__ Water Supply:'Public;*terri ❑ Corrimunity system A Private ❑_ Depth to'Wafer Table cZ:F�ft. Character of.soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 0 Clay ❑ Adobe [M Hardpan ❑ Previous Application Made: Yes ❑J No IL New Construction: Yes No E] ' TYPE SOF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200-feet.) Septic Tank: Distance from nearest welL&"-—______Distance from foundation----/A--r______-Material��_ No' of compartments_____.__-a-.-__------Size___ _._ _ Liquid depth_____. ___ QCapacity... Disposal Field: Distance from nearest well.- r____Distance from foundation_____�G_____---Distance to nearest lot line_ Q Number of lines'______�____f___ -Len th of each line______.. Width of trench.___ _ _ /r /= j Type or filter material____ ..�___= __Depth of filter material!/—______Total length___.__ ______________________ Seepage Pit: Distance to nearest:well__d _.___. Distance from f undation____�6____._-.Dista�e to nearest lot line____ 1 Nuu{rnberof pits-- -- -------------Lining material--�- i Diameter'__B_'$___-_-------.Depth----- - �__ ___�--------- Cesspool: Distance from nearest well__________------°Distance from foundation--.----.,-------- El material__________..____-._.________________. Size: Diameter__ ._______1De th__________________ ____._.Li Liquid Capacity __gals. (� r --=; ------- ------------ -- - - - - - , g--------------------------------. _ ! Priv � Distance ��rom nearest well______________ Distance from nearest building � t ❑ - .—Distance to'nearest lot line------- - --- A - . ------------------- Remodeling --- -- -------Remodeling and/or repairing (describe):---------------------------- -----------------------------••- i I ------------------------------------------------------------'---------------------------------------------------------------------------------------------- ----------:--------------- ----------------------_----------------------------------------,-------------------._...-.---.---------------------------------------------••--- --------------------- ' I hereby certify that I have prepared this application and that the work will be°done in accordance with San Joaquin County ordinances, Stat ws;and rules and regulations of the San=Joaquin'LocaPHealth District. , (Signed} T - I ` c --.--(0 ner and/or Contractor)--------------ma . --- - _ ------(Title)---- -------------------------------------------- (Plot plan, showing size of lot; location of system in relation to wells, buildings, etc., can be placed on reversd side). I s - t s FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------- --------- -------------- DATE REVIEWED BY-------------=----------------- - --- <37 ------ -------------------------------------•--•-----. DATE----- _------ .:- -••--------•---------------------- aDAT PERMIT ISSUED---==---------=-------------- - ----- --- `•---- ---------------------------------------------- •-----•--- Alterations and/or recommendations.-------------- --- D'-----------•------------- -•---------•------•--------- --------- ------- I F s S ---------- _------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- e J- J FINAL-INSPECTION BY.--------- '`- ------=--•- '= :: d,... Date--------------- •----- ::_- = ----- =---------------------- '------------ SAN ---------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814North "C"Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M ; ' Revised W-2100