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APPLICATION FOR SANITATION PERMIT .. Permit No. .__ t_Q_ --r]---• (Complete in'Duplicate) 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. S�a JOB"ADDRESS AND L CATION___ -_-_-_ _ _ Owner's Name_ .!_f --- ---- --wl l bl/,' .S_ �� Address �� Vf ,��= t>./jfff Contractor's Name____='�__.__,---___ •_ -_•--------•---•---•---------------------------------------------- - - -- ---------------- Phone ' Installation will serve: sResidence Apartment House Commercial ' ❑ ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-.1 r_ Number of bedrooms 4.._ Number of baths __ _____ Lot size _29-10cF Water Supply:' Public system ❑' Community system ❑ Private,N Depth to Water Table 6koft, � I Character of soil to a 'depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ ' Clay ❑, Adobe IN Hardpan ❑ Previous Application Made: Yes-2—No A New Construction: Yes;N No ❑ TYPE OF INSTALLATION AND„SPECIFICATIONS: R (No septic'fank'or cesspool permitted'if public sewer is available within 200 feet.) Septic Tank: ►Distan e from.nnearest Well__a_ Distance from foundation___ �- Materi ._t lJ-p ' - - ------ No. 4 ck- of compartments..4 . �- -- - ------------ ��-�- -- _ �I ,_Liquid dep. -- ---- - , -----Capacity - h -- Disposed Field: Distance from near st well ,Distance,_fro foundation___;�� _-Distance to nearest lot line___.,C Number of lines,--- O________Length of each line ___-- - �r g ---- -(e4--__.Width of french----•---- ��P-�� --- ------- Type of filter material- -3 -,- Depth of filter ma'fe'rial_--- - -• ----------------- Total length-----/._�----- t ,Seepage Pifi: Distance to nearest well__.________________Distance from foundation-------------.------Distance to nearest lot line_____.______ ❑ Number of pits----------------------Lining material---------------------- ` f .. .. __�...,.,. Size: Diameter-- _.Depth Cesspool: Distance from nearest well_________________Distance from foundation___.---------------'.Lining material--- --------- ❑ Size: Diameter ----------- ---------------De th__ -- -------------------------------------- -------Liquid Capacity-.--- -`gals. Privy:: Distance from nearest welt__ _____________________________ _____________Distance from nearest building_-_______.__---____ ❑ �- Distance to•-nearest+lot�Iine-�-':_--- `----- ' - ------------ - a -------------- Remodeling and/or repairing (describe): -- __--_ - -------- -------=--------- -------------------------- --- 9ulafion, pl?li a� non and,# - I hereby certify that ! have prepared this a Iat ----------------------------- ----- �the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and're s�of`the San Joaquin Local Health District. (Signed)---- _: ----------'-------------------------------------------------` ' I �,., Owner and/or Contractor] sy:----------- - --------------- (Title) 3 ` (Plat plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY - r APPLICATION ACCEPTED BY -- --------- DATE . . REVIEWED•$Y - „ _ DATE--------------- ......-=---- --------------- BUILDING PERMIT ISSUED - - --------------------- DATE-------------- . ,� y Alterations and/or_recommendations:-___r__.___-_ A --- ----:. -----------------------------------------_--------------------- - ;+.. - .. __________________________________________________________ I 40y __.__.._.--------------------------- ________________________________ __ FINAL INSPECTION Date.-- 4e p' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street t', 't \. 132 Sycamore Street-- ' ' 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California r _ ES-9-2M ; . Revised W-2100 }