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APPLICATION FOR SANITATION PERMIT Permit No. :___`�_f.&�__ _,•- (Complete in Duplicate) Date Issued r �_2 C_� S Ono— 4'7 Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descried. J� This application is made in compliance with County Ordinance No. 549, L I JOB ADDRESS A D LOCATION 0----!V-�.j"r ��_ w � C t. . � �n -e t- - Owner's Name. - . 'E'.�� t " - �' K �L t _------ ----•-- •--- - ------------ Phone. Address__. "~ ----- -- -- - -fi Contractor's Name----- __1C7--- _t------------•. �l ��` �4 1=� -- Y I -----_ Phone--- Installation - -- ---------------•----------------�-------- Installation will serve: Residence 0�artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of iivin� units: -__-- Number of bedrooms--_;;3- .Nu - 't `7 g .':Number of baths_- dot size ---- ------- --- --- �.w _ f� -------•----------- Water Supply:' Public 's�stem Communif s stemPriv'a' te' b. '�rp 'r T i PPY� Y ❑ y y ❑ Private De th to Water Table Character of soil to a depot of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑' No [ New Construction: Yes to ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted 4f public sewer is available within 200 feet.) Septic Tante: Distance from nearest well_ (_ --Distance f_rom foundation__._ __ Materiel------_ -- 14— No. of compartments-__- i --Size-----!7--- ----0--.Liquid depth ------------------ ----Capacity--J-- J Disposal Field: Distance from nearest well----- Distance from foundation____? Distance to nearest lot line__` Number of lines_______________� -"_-"------_-Length of each line__.____j__�l___.__-- -• t�-Width of trench Type of filter ma ria -� -_-- Depth of filter material____-l ___.-_Total th_______A-� - -------------- length lZ Seepage Pit: Distance to nearest "Well----------------------Distance from foundation--------------------Distance to nearest lot line_______________. k„ ❑ Number of pits--------- ------------Lining material----------------------.Size: Diameter-----------------------Depth------------------- Cesspool: Distance from nearest well-----------------Distance from foundation----------------i----Lining material__---------------------------------- Diameter-- _ ❑ _ _,.x.5ize: -=_` T---------=-=------- - Depth------ _ .- _ - liquid Ca pacify 4�'. ..s: .... . -_ Privy:, Distance from nearest well- ____--_ -____-_Distance from nearest building Distance to nearest , ` ' - r .. Remodeling and/or repairing (describe)_________________________________ " --•-••----- ---------------------- ---•------------------=-----------•-----------•------•- - -------------------------------- •--------------------•- - -------------------------------------- - ----•----•----------------------------------------- -------------•--------•----------••------------------•---------- ---•------------------------------- I�here6y 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) i --- --- ••-------------------------- ------------- -----------------------------------------------------------------(Owner and/or Contractor] By: --------------------- ' '-- --=----------------- -_-' --------------`=___---:---------------=------(Titl e) _� (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATI�NACCEPTED BY------------ --- DATE-.----- --_"_1-- > --- -------- ------------------ ------------------••---------EVIEWED BY--------------------- ----------------------- ----- ----_ DATE ........................................ ------------------------------------------------ l1ILDING PERMIT ISSUED-------------------------------------- ---------- DATE---------------•----------- -- -- - -------------------------- terations and/or recommendations___---------------.----------------------------------- ---------------------•---------•----------•---------" -- --• , -------------------------- ---------•----- ---------------••---------- r FINAL INSPECTION BY._- �_<– �� Date-'.---- t 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 Revised W-2100