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APPLICATION FOR SANITATION PERMIT Permit No.0-0, 1.__.. (Complete in Duplicate) Date Issued ___�l��s. 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. w. r S JOBADDRESS AND LOCATION---------- -- --(°-------------------- ------------------•- ------------------•---•----------------------------------------------------------------------- Owner's Name-------------B___4-------- ----------------------------------------------- ------------------------------------------- Phone.__4-4.f_CV__/-------- Address------------- ----- --- Address------------• ...........6--1--C----------W-A-r 2715'----------------- -------._._.---------------------------------------------------------------- Contractor's Name___---_--•- _ P __ R-- f S Q ----------�--�G - Phone Installation will serve: Residence [`- Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�-_-_ Number of bedrooms _A__ Number of baths ---/--- Lot size ---�d--------�__--_-�.a____________________ Water Supply: Pub€ic'system ® Community system ❑ Private ❑ Depth to Water Table'l1a__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ® Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: l- , Distance from nearest wel ________________Distance from foundation _ _ _ _ __ ---------_-____-._.Material__-___________ - --_.-.- _--_--. _____._ - VZl,+ -VO No. of compartments--------------------------size--------------------------------Liquid depth---------------- -------- Capacity----------------------- Disp l Field: Distance from nearest well-----------------Distance from foundation--_---_-________._.Distance to nearest lot line------ Number of lines---•---•---------------------------Length of each line------------------------------Width of trench--------------------- Type of filter material-------------------------Depth of filter material--------------------___Total length__________________________________________ Seepage Pit: Distance to nearest well_1Y_11yC-_---Distance from foundation------f p__--_.Distance to nearest lot line-_47------- XNumber of pits--------1-----------Lining material_C C__6_9�`#Size: Diameter__-__ ......Depth-----3_L----__________________ Cesspool: Distance from nearest well-----------------Distance from foundation-- .------___.___.Lining material---------------------------.__._---_ ❑ Size: Diameter-------------------------------------.Depth---------------------------------------------------.Liquid Capacity- ------•-------- ---------gals. Privy: Distance from nearest well------------------ ------------------------------Distance from nearest building----------------------------------------- 11 -----_ ._❑ Distance to nearest lot line----------------------------------------------- -------------------------------------------------------------------------1- ------------- Remodelingand/or repairing (describe):--------------------- ------------------------------•-----------•------------------------------- ----------------------------------------------•-------- --•--••-------•--------------•------------•-----------------------•-------.....------------------------------••--------------------------------------------------------------------•-------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ------------------------------------ --------------------------------------------------------------•--I----------------------------------------------------•--------------------------------------------------------------- - 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} 1 9 ----/-------/ A-- a -- - 1 �� = (Owner and/or Contractor) By:--------��- ` ----- (Title)- - (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------------------------------------ V-�-&----------------------------- DATE------- -5-3----------------- REVIEWED BY--------------------------------------------- ---------------------------------- ------------------------------ BATE ------------ -- ----------------------------- BUILDING PERMIT ISSUED-------------------------------------------------------------•----------------------•---------------- DATE--------------------- ------------------------------------- ---- and/or recommendations:----------------------- --------------------- -----------••------------•-------------------------------------------------------...._ •--•------------------------------------------------•------------------------------------- -----------------------------------------•---------------------------------------------------------------------------•---- ------------------------------------•-----------------------------------------------------------------------------------------------------,---------------------------------------------------------------------------------- ------------------------------ --------------------• ------•----------------------------------------------------------- ----------------------------------------------------------------------------------------------------- .� ,' // `�_' FINAL INSPECTION BY:------------------------• / � Date------ ,f -- .�''�__ ----------------------------------• SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21M 10-52 Revised W-2100