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APPLICATION FOR SANITATION PERMIT Permit Nol.5Z. fw (Complete in Duplicate) Date Issued - _ Vey. w 130--Z� Applica+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 incompliance with County Ordinance No. 549. a + aW=� pI'+ �'y( (�e,� 5�i4 a �sos 1.. x JOB ADDRESS AND LOCATION.. Owner's Name---- �?Q�d7 --. l-At- Phone Q__• tQ s ; Address--------------------_--= ��Q-. d s Y i Contractor's Name____________P '!I't- !7-�--____________._ Phone- Installation -- ---------------------------------------- --------------- Installation will serve: Residence Ar Apartment Hose Commercial ❑ Trailer C6urt ❑ Motel ❑ Other ❑ Number of living units: - --- Number of bedrooms ____ Number of baths - -_ _. Lot size , I Water Supply: Public system ❑ Community system 9 Private ❑ Depth to Water Table'Aft. 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 EOF INSTALLATION AND SPECIFICATIONS: rai (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest Distance a from foundation_IO s No. of compartments_1�.._________________Size_► __14_ _ '�._.-Liquid depth.-_ �*_..____ Ca aat .. Q,Q- 0I4S aterca_____ �� 0• t Disposal Field: Distance from near" t well__>�-JQ----,Distance from foundafion_� --- � ______ _______Distance to nearest lot line.._.. _..... Number of.lines---.--I--------------------------`Length of each line------45-0----------Width of french_.A9Cif!------------------ Type of filter material__I)_%,`N?k------Depth of filter material---1�-�._____-__Total length__ �---p_�--------------------- Seepage Pit: Distance to neare-s� well_ ,CV-0"-Distance f m f undation__r"_.'___.Distance to nearest I t lid j._--�-Q� Number of pits_____ _______________Lining matersal ---Size: Diameter----_,-3 W __..Depth_-_-- ._ ___-______________ Cesspool: Distance from nearest well.......----------'Distance from foundation.__------------------Lining material-___________________.___.___---______. ❑ Size: Diameter--------}-'----------------------- 'Depth---------------- I---------------------------------Liquid Capacity--l---------------------gals. Privy: Distance from nearest well_-___„__. =_______ ______________________Distance from nearest building_____------- ________-_.______________._. ❑ Distance to nearest,lot line- ------------------- w Remodeling and/or repairing (describe):--------------------------------------------•-----------------•-- .------------------------------•--------=--•-----------•------.._..------------- - .. ------------------------------ --""--^'— -- ------------------•--- ---'--------- --- --------- ------------------------------- r I here certify that-I epared his a lication and that the work will be/done in accordance with San Joaquin County ordinances, State laws, a d s an r ns f the a quin Local ealt istrief. (Signed)- •---- ------- ----------------------_---- ---��”-`----- ---- ------- --- ------ ---- = ----------------- ------- --- ontracfor) By:---------------------I.,—---------------------_----------------------- ---- ------- ----(rifle)-- � �------------ (Plot plan, showing size of lot, locati6n of syste in relation o wells, ildings tc., can be pla d on reverse side). } EPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------ -------------------------------------- DATE s _ __ _ _ _ ___._______________ '. REVIEWED BY ------------- --------- ------------------------------ Il-�_� -------------------- DATE � ((((//// BUILDING PERMIT ISSUED-------------- j ------------------------------------------------------------------------------- DATE Alterations and/or recommendations: -------------------------------------------------- -------------•-------•--•----------- ... ---•------------------------------------------------------------•------------------------- •-------------------------------------•-------------------..--..-------------------------------------------•----------- ---------- 1 f ----------------- - ------------------------------------------- ------------------ J / FINAL INSPECTION-BY:.- - L�---=-- Date ( l ` SAN JOAQUIN LOCAL. HEALTH DISTRICT 134 South American Street _ ,1300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100