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APPLICATION FOR SANITATION PERMIT Permit No. 4-43_1--_-__ y�, (Complete in Duplicate) {{ _ qq �, -� } )made f A�Date Issued l�__.S_�____`�3 ( 7-4 L I?O--YZAppli tion is hereby to the.Son Joaquin Local Health District for a permit io construct and install the work herein described. This appdo made in complianceIwith County Ordinance No. 549:' JOB ADDRESS AND LOCATION._ _____ _ _ ! .-Il. "" p " Owner's Name--------- ---- -- -------- -----•��. ..------------------------------------- ----------------------------- Phone-- -- Address--------------------- ----------------------------- •. f , ; . ----------------------- --p.. - --------------------- Contractors Name 'Ap -------------------------•------------------ ---.- --- ----------------------- Phone------------------------ ------ Installation will serve: Residence Apartment Hvuse,❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Ej Number of living units:.-___ Number of bedrooms _--YNumber of baths -_/---_ Lot sizetj Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table --s -f - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ) Hardpan L]YesApplication Made:-Yes El No New Construction: Yes No E] TYPE OF INSTALLATION AND SPECIFICATIONS: Septic Tank: Distance spool permitted if public sewer is available within 200 feet.) No septic tank or cess: om nearest well--� ---Distance fro foundation_.-f O --------.Mater• I____._�!apza�ci No. oftom artments- ! Li uid de th--.__ _p �"' Size g q p Dis osal Field: Distance from nearest well_- Q- Distance from foundation-----70-0-_--.-.Distance to nearest lot line*2'�Q.---- ] Number of's lines-----------)----__ _._-_-__-_ _Length of each line---_4 f_g Width of trench---_- p _ - -- -----. Type of filter material----5��.Depth of filter material----.- ...........Total length---- --..-------_-__---_- Seepage Pit. Distance to nearest well----------------------Distance from foundation_--_--______-_---.Distance to nearest lot line-----.-_.---_---- ❑ Number ofipifs----------------------Lining material-----------------------Size: Diameter---------- ------------Depth------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation-_-. _-----------Lining material------------------------------------- r,. - .. Depth- ------------------------- -- -- -- --- - ------------------ ------ ---- - - --- -----Liquid Capacity _gal Priv❑ D sta�e m otmr nearest well ---,.»..�..-T- ,.,.....��..��.,-.� - . -- } :-- vim.,--_-,-�. r�•- - _ .__.�„� -------------------------------- -----------Distance from nearest buildin ---------------------- ❑ Distance to nearest lot line s Remodeling and/or re�a'iri ( astir } _. ._t_._�er-____ eG--. - 2 _ � �, - - - r-- ----•----"x.5:11- - �� --------------_-_.-..---------------------- -- ------- ,.� -� -- Lar-�� a,,,r.---•--�--c---�-•- - �--------------------------•---------- �------------- --------i------—-------------------••--------•------------------- ------------------•-------------------- -hereb---taint---that I - .1---------------- ----'---------------------------- ------------------------------•----------------------•------ -- - ------------------------------------- y y e 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. 1 (Signed)... -----------''" Y r ' _--____(Owner and/or Contractor) By.__ ---------- -- ------------ ----------------------------------------------------------------------------(Title)-----------------------------------•------------------- ------ (Plot plan, showing size of lot, Iota+ion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ------------------ ----------- DATE-------------------- - --�-------�--------------------- REVIEWED BY----------------------------°'- -- -X /J t DATE -- .Y - BUILDING PERMIT ISSUED.------------- if- DATE } - � .. Alterations and/or recommendations:--- -------------------------------------- = ------------------------------------• ----------------------------------------------------------------------------------------------- ----••---------•=--------------•----------------- ---------- ----------------------------------------- - -----------------•---- -- ------------------------------------------------------------------- -- --- ---- //,2 ' ------------- Date.- ---- -- ------- i FINAL INSPECTION BY:------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California h Lodi, California Manteca, California Tracy, California ES-9-2M io-52 Revised W-2100