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._ -. -APPLICATION FOR SANITATION PERMIT Permit No. ,I (Complete in Duplicate) Date Issued f � I q � 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. 11 JOB ADDRESS AND LOCATION..__-��-_ -_� ------- .- - -- - --- ------------------------------------•-------------- ---------------------•-- Y Owners Name---- ------ ---- --- --- Phon -•`!�,.C'' '�---- - �- . -- ----.-------- Address_____________ _ -- --- • _/-----�-- Contractor's Name. ----- PhoneI C Installation will serve: Residence ❑ Apartment House ❑ Commercial [�'�f railer Court ❑ Mote! ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths _-�Z Lot size -------- pe th to Water Table ft. Water Supply: Public system ®-<ommunity system ❑ Private ❑ ,; p 7 Character of soil to a depth of 3 feet:' Sand [jGravel [I Sandy [IClay Loam ElClay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes Er-lgo ❑ I € TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer isyavailable within 200 feet.) lF __________ Septic Tan Distance from nearest well-----------------Distance from foundation-------------------- No, of compar#menu ----------Size--------------------------------Liquid depth - Capacity Disposal Field: Distance from nearest wel ►lL„ Distance from foundation_-- -_-.--- Distance to nearest lot line- Q-.r----` Number of lines:---____-- Length of each line-_-.-_o`Z-lt_!--�,- --.Width of trench---.�-- ---------------- ----- 1 Type of filter material # f� Depth of filter material. ' '' Total length -�•- Yp e9 Yt ' Distance to nearest wsll ,d722.._---Distanc fr foun tion---%` - --------Di lance to nearest lot line��a___- __ Seepage L s5_ Linin materia ize: Diameter__..- ----__-..---_-_-.Deptn_--- ----------------- Number of pits_---. _----_ .- - g I Cesspool- Distance from nearest well-----------------Distance from foundation------------------- Lining material------------- ❑ Size:=Diameter._ -=_ ------------Depth------------------°---------- -- -- Liquid.,Capacity - _� = gals. _ ~, Privy: Distance from nearest u�elL________________ Distance from nearesT building_-._______.__.ry_f_______•-------------- ❑ -------------- of Distance to neares}"lot line-- ---------- ---------------------------------------------------------------- -- Remodeling and/or repairing (describe)------------------------------ ------------•-------••--------------- ----- -------------- ------------------------ ---------------- -----••------------•----------------- -- -•--------------------=-------------- ------------------------------- •------------ I-------- - 4 - - - --------------------------------------I - ------------------------ i that +he work will be done in accordance with San Joaquin County I hereby certify that I have prepared this application and 2 ordinances, State laws, and rule;and egulations of the San Joaquin,Local Health District.�} ------------------ .O. er.and/or Contractor) Si ned �Y 1�-- -- je'l- - - - - --- -- OIL /� --------------------{Title)-------------- -------------------- ---- , # (plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side)] II FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.__- �•------ - -- ---- - --------- D/1, l-7 ----------------- REVIEWED BY-------------------------------- ----------------------------------------- DAIE-------------------------------- - - II ' BUILDING PERMIT ISSUED------------------------------•-•---------------------- --- DATE ;; Alterations and/or recommendations:---------------------------------- ------------------------------------------------------------------------------------------------ -------- -------------------------------------- - - - •--------- --------------------------------•-----•-----------•-----•----------•-------•---------------------------------- II-------------------------- ----•------- ------•-------•-----• ---•--•----- • ---------•----- -------------------- ----- ---- ---- ------------- -------------------------------------------------------------------=---- -------------------------- -------- - --- r _ ---------- ------------------------------- --- 011 FINAL INSPECTION BY______________f - -- Date- =,I I SAN JOAQUIN LOCAL HEALTH DISTRICT h 300 West Oak Street 132'Sycamore Street 814 North I�'C" Street 130 South American Street Trac C1lifornia Stockton, California Lodi, California Manteca, California Y. :1 s( ES-9-2M 0-52 Revised W-2100 '� 3`