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APPLICATION FOR SANITATION PERMIT Permit No. _ .__.... 0� k (Complete in Duplicate) Date issued ___ ____ 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---- ' 11-----/ ---------- ----------------------------•----------------------------------- Owner's Name - "1.0-1_a_- �tI�IY_�, iUsi Phone =t zPf Address-- �t,�� y+?,r------c !Y Z'�-!1 =51---------------- ------------•-------- ------------------------------------.. ---------- Contractor's Name �"'� 1� Phone----�`f-APy�------- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other &161444Ual Number of living units: -------- Number of bedrooms ________ Number of baths !_----- Lot size ___________ ___ __ 7_X_�� __ __ ------------ Water Supply: Public system $, 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 X Hardpan ❑ Previous Application Made: Yes ❑ No Z_ New Construction: Yes X No ❑ i TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if, ;blit sewer is available within 200 feet.) Septic Tank: Distance from nearest wel _-__Distance, from foundation_l_Q_._.........Material-_&C'�c ___________-"_____________ No. of compartments --____________ Size_o%__'_A _ _:__.Liquid depth_o _��__-_-.____,-Capacity._SvQm__9!�'__-___� blb rorm Disposal Field: Distance from nearest well.��t.._Distan e aundti aon_l4_r--------Distance to nearest lot line_____�'�_.- Number of Iines,3-_-�LjkLl)lta,. lLength of each line__t_Q_ ------------------Width of tree h!_--�_7p��-_____"- Type of filter material---I'rr�____Depth of filter maferial---r_��--------Total length=arest lt ¢.+___f�ory � Seepage Pit: Distance to nearest well (..QliC-__"_-_--Distance,f m, foundation__.A0_______._-.Distance to® not line----- 60 Number of pits.__..__________-_---___Lining materialCr ____ A- ��_.___..Deptn___�Ca_aS- Size: Diameter__- ________________ Cesspool: Distance from nearest well------------------Disfance from foundation--------------------Lining material:_x� -------------------------------- ❑... Size: Diameter _:-,.-----------------------Depth - ��. -__ Liquid Capaci.tY= =— = = gals.- - - ----------------- Privy: g Distancer.from nearest well----- ----------------------------- .Distance from nearest building------------------------------"---------- . ❑ Distance to nearest lot line-----------------=------ -------------------- ---------------------------------------------------------------------------------"--------- " e Remodelingand/or repairing (describe):------------------------------------------------------------------------------------------------- =---------"---------------------------------------•----- -------------------------------•--•--------------------------------•------------------------------------------------I-------------------------------------------------------------••-- ---------------•------------------------------------------------` ----------------------------------------------------------------------------------------------- ------------------------------------------------------------ I 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. I ------------------•------------- --- -------------------- :---------._.Owner and/or Contractor (Signed)---------------------------------------------------=•------------------------------ � / ) 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 a APPLICATION ACCEPTED BY DATE---------- REVIEWED BY-------------------------------------------- -------------------------------- ----------------------------------------------- DATE ------------------------------------`S - BUILDINGPERMIT ISSUED---------------------------------- -------------------------------- ---------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:__________________"_ ' --------------------------------------------------- -------------------- -------------------- -----------------------------•-----------------------------------------------------------------------... ,----------•------- ---------------- -•---------------------------------------------------- -------------------- -------------------------------------------;---------------------------------------------------------------------------------- ------------------------------- - ---------------------I----------- - ---- -9--------------....------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY: (/-"_'_ 1±° Date--------------------- / - �� ------ - -------------------------------------- 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 E5-9-2M 10-52 Revised W-2100