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" APPLICATION FOR SANITATION PERMIT Permit No. x_,11.7_... " -(Complete •in•Duplicate) -4 „5 Date Issued ____�_o�________.. 1-7l- rao q Applica4-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 in compliance with County Ordinance No. 549. SOS ADDRESS AND LOCATION___Sr__10_—Z__4_.Z 4_`.-. Owner's Name--..--- -i ---------------- -------- --- - Phone-_--..------------------------------ Address-----••... ..1 �..- -G. � ------ x >t' �' '--- ''-------•-------•---•----••---•-----------•------- Contractar's Name '.% ----------- y -------------------- PhoneQ 4 d Installation will serve: Residence ❑ Apartment House [- Commercial ❑ TrailerCourt ❑ Motel ❑ Other _ Number of living units: ________ Number of bedrooms ________ Number of baths __/�_Lot size ------ �_____________ ___________ F Water Supply: Public system ❑ Community system ❑ Private 9 Depth to Water Table .-0 ft.'- Character t:Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ Noj% New Construction: Yes � No [ITYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank'or cesspool permitted if public sewer is available within 200 feet.) 4 Septic Tank: Distance from nearest well-2-OP_ ` Distance from foundation___ Material of compartments------ 2 _1 ._ _Size-- --- d-----•Liquidep - T� -----Capacity--��a-41------f- - Displ•Field: line t �. Distance from nearest weh__;Z A____Distance from foundation_____ 4__._..Distance to nearest lot line____ .._ 1 -Length th of each line________ " 9_______.Width,of trench-___.1�/__'?------------------ Number of lines-------------�--� •--- - - g �------- ij f Type of filter material.__,tf�___--- I--Depth of filter material____._ Total length______Aja_________________________ Seeps e Pit: Distance to nearest well___�_bp_____Distance f om sfo ndation______�0__._-Distance to nearest lot line___-_ Q____ Number of pits--------/--_--______Lining material___l ___Size: Diameter____f0-�__--_____.Depth_____. _--_____________l ` ! Cesspool: Distance from nearst well-------- --------Distance from found ion_-________._______.Lining material___._____._-__________`.________-. [] Size: Diameter----------------------- =--------De,pth----------------------- -------------------------Liquid Capacity......'.---------------------gals. Privy:IDistance from nearest well-_______________________________________________Distance from nearest building-------------- ----------------------------- __0 ❑ _ , Distance to nearest:lot line----- --------------------------------------------------------------------- --------------------- --------------------- Remodeling and/or repairing (describe):---------------------------------- ----------------------------------------- ------------------- ---••----------..._..---------------•----------------- ----------••--•-------------------------------•-------------------•---------------------=---------------------------------------------------------------------------------------------------------------------------------- r 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. (Signed) �.� ----, -- ------ --- --- (Owner and/or Contractor BYL --- ---- --------------- (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 APPLICATIONACCEPTED BY - - ------------------------- ---------------------------------------- DATE------- - -------------------------- REVIEWED ------------------------- REVIEWEDBY----------------------------------------------- --------------------------•- -------------------------------------- DATE------- T------------------------ BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------------- al --------- Alterations and/or recommendations: ------ -----• -----------------------•--.-----------_ -----------•--------------•-•... ••... .. - - ------------------ ------------------------•-•-------------------------••-----••------------------------------------------------------------------------••----------------------------_---------•---------------_------------------------------- F ----------------_----------------------------_---------..-----_--_-____._..--______._._______._________.__.____.____-_______._ ____-______________. a-rt _________________________________________________________________.._______.._._•________-___-_-._-------_--____________________________-______.___._______.____________-_ ------------------------------_----------_-------------------------------------------_____________________------------------_----------------------------------------------------_--------------------------------------------- � _ f4f 1 FINAL INSPECTION BY-------------------------- - -------- 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 ES---9-2M Revised W-2104