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APPLICATION FOR SANITATION PERMIT Permit No.C)_E (Complete in Duplicate) -, Date Issued -- _j_7--5 .2— 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. JOB ADDRESS AND LOCATION__"4 _- ----------►ip"[`1 4_lE-v%(----AYti_►-------1,- 6_-T -----1P+--6V41AxVA_-.--! rs_m----vkl_�"a Owner's Name------ •....... Phone _ ------- I - Address------------------�K-T �'o-�..�-C,�-'-''�--�--� -- ��-�---------------------•---------------------------------------------------- -- ----------------- Contractor's Name NO _ D - - ------ -Q Phone `. =' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � c Number of living units: j---- Number of bedrooms 3--_ Number of baths ---I---- Lot size -_--__ t?."_?�-""Z" Q- Water Supply: Public system D-1-Community system ❑ Private ❑ Depth to Water Table -------- ft, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan Previous Application Made: Yes ❑ No X New Construction: Yes f4 No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) x Septic Tank: Distance from nearest wet;---ttZ_H__Distance from foundation------LO t-_Material cDY l_ No. of compartmentsZ-------_----Size "X---9_k-------Li Liquid depth - -Ca y ASL-, p -�` q P -- - --- pacit __$t!�""f Disposal Field: Distance from nearest qwelt_ -------Distance from foundation---�1C!-------Distance to nearest lot line_,_-5_"___--- '� Number of lines____-----_"ll-----------------------Length of each line-------�' --------------Width of french------- ---< _--__- Type of filter materiaL_�72R�Cf�Depth of filter material_____Z_1_"-"-__Total length-------QK-T----------------------- ! c : S pa e` Pit• istance to nearest well---"_r' ----------Distance from foundation-_ ki Distance"Q___--_-_. to nearest lot line"r"�__--___ umber of its-___---__(<___--_-__---Linin material._ ��--._ .Size: Diameter-_--_- C p g - - ------------Depth---------�---------------- Cesspool: Distance from nearest well----------------- from foundation------------------- material___--__--_---_------_-___-______----_. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------------------"Distance from nearest building____-_"-_"--_-_---_-_-_-___-----_----___. ❑ Distance to nearest lot line------------ ------------------------------------------------------------------------------------------------------------------ Remodeling and/or repairing (describe):--------------------------------------------------------------------------------- --------------------•-------------------------------•---------------- ---------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------•-------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------- 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)--------------------------------- --------------------------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:------------------------------------------------------------------------------------------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------------------------- ---- --- -- ---- ---- DATE REVIEWED BY --- ------------------ DATE BUILDING PERMIT ISSUED---------------------------------------------------------------------------------------------------- DATE------------------- Alterations and/or recommendations-------- ------------------------------------- Y --------------------------------------------------------•-----------------------------------------------------------------------------------------------------------------•----------------------------------------------•--- ------------------------------------------------------------------------------------------------------------ ------------------------------------------------------•-----------------•-------------------------------------- ---------------------------------------------------------------------------------------------------------------- --------------------------------------I---------------------------------------------------------------------- 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-9-2M 8-51 Revised W-2100