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�5 ION FOR SANITATIONPERMIT Permit No. .. .V6�- APPLICAf (Comple#e in Duplica#e) Date Issued?-`— D R5-- 1-?e,?--i�F Ap plica ion is hereby made to the San Joaquin Local.Health District for a permit to construct and inst 1 fi e work herein described. I s application is made in compliance with County Ordinance No. 549. AJ JOB ADDRESS AND LOCATION-------------------7------Y -------- U �Q /4 ---�AU-- --------------------T>,�G/yr--- :/ `� r Owners Name = J--r.7- ` 11__--_-J--�E_Li1.4f2�T" ------------ Phone----•---------------------------- Address----------------------------------- --------------------------------------- ------------------------------------- ---------------------------------------- Contractor�s Name---------------�0 _ _ o N.._._C�d/1_ / .ClC lo-h/----------�--------------------------- Phone-------- --------------•---•------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court L] Motel [] Other Lj Number of living units: -�_-'__ Number of bedrooms._ Number of baths _/___ Lot size X__ Q_______________ Water Supply: Public system ❑ Community system [7"Private ❑ Depth to Wafer Table __ ___ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Lo;'-PNo [j Clay Loam ❑ Clay ❑ Adobe [Hardpan-❑ Previous Application Made: Yes ❑ No [p- New Construction: Yes " TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic` nk: Distance from nearest well__ Distance from foundation__ No. of compartmenfs__I�--------------- 3 Liquid depth____;____.._.________Capacity_____ y Size_.......- / n Disposal Field: Distance from nearest well___ Distance from foundation--- __,.Distance to nearest lot line----.5...__.__. - .Width of trench. Number of lines_________'�r' .__._:._- - Length of each line__ - � Type or filter material -_ epth of filter material_______ _______Total length--------------- ----- Seepage Piti Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line________ ❑ Number of pits---------------------Lining material----------------------.Size: Diameter-------------------- ----Depth.---------- i 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-------------------------------- ____--___ J ❑ Distance to nearest lot lire-------------------------------------------- - -------------------------------------------------------------------------------------•------- v i - - Remodeling and/or repairing (describe)____________________ . ------------------ -----------4 ---------------------- ----------------------------- ----------------------------------- ---------------------------------------------------------------------------------------_--------------------------._-------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San'Joaquin County ordinances, State law nd rule an re ulations of the San Joaquin Local Health Qistrict. (Signed} ------ ----- 1---- ---- ------- (Owner and/ r Contractor --r- --- - ----- --- (Title} ------------ ----------------------- ------------------------------------------ -------------------------------------------- ----------------- --------------------- pian, showing size of lot, ocation 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-- •---- 1. __ ------------------------------ - BUILDIN ----------- BUILDINGPERMIT ISSUED-•--------------------------•---- ---------•-------------------------------------------•------------ DATE----------------------- ------------ Alterations and/or recommendations----------- ------------------------------------- ------- ••--------------------------------•--•----- -------- •---•----•-•-----..__...----••------------------• : -----------------------------------•--------------------------------------------------------------------------------------------------------------------------------------- ----------------•------_--•--••---- -•------------------------------------- --------------------------------------------------------- ----- -•--- .-----• ------ ---------------------------------- - ----------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------- / r �. r FINALINSPECTION BY----=------------ --•------------------------------------------- Date--------------------------------------------'----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Ameririn 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