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Permit No A_"1_.--A 7• � APPLICATION FOR SANITATION PERMIT _1 sky (1 (Complete in Duplicate) Date Issued _--!-- __3_ _,S 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--- - 1)___7--- -------- -- ------- - - �� f t�� - --- ---- ------------------------------------- Phone_+' Owner's Name__:��✓_�..- i-------- ----' ------- ----------------------------- ----------- Address. + ` - ----------------------------------------------- - :.-_ Phone- Contractor s hone-Contractor's Name_-- ._-- - Installation will serve: Residence lApartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other [3 ^ Number of living units: Number of bedrooms -3-__ Number of baths _-2. Lot size ----� __, --- -- 6 -___----_-_-______----_ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table 7T ft. Character of soil to a depth of 3 feet: Sand F1 Gravel 171 Sandy Loam [I Clay Loam ❑ Clay El Adobe Hardpan E] Previous Application Made: Yes ❑ •No;<, New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ' Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material-------------------------------------------------- {t No. of compartments--------------------------SizeLi uid de th--------------------------Capacity-_ F Disposal Field: Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line____.-__-.--_---. rt ° Number of lines-----------------------------------Lengi-h of each line-----------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material---------------- ------- length-------------------------------------- Seepage Pit: Distance to nearest well_ Distance from founclation__----a--- .___..Distan Re to nearest,�o+line_-- 4-44 Number of pits------1--------------Lining material---4_M-- --Size: Diameter__-- -------------Depth-�F_ '�,--_----------w { Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining ❑ material----_-_-------__----__-----__.-----_ Size: Diameter ----• ----De th----------------------------------------------------Liquid Capacity---------------------------gals.. Privy: Distance from nearest well__-.--""______----------------------------------Distance from nearest building___----____----_------------------------- ❑ Distance to nearest lot line------------------ -------------------------------------- ------ ------------------------------------- s Remodeling and/or repairing (describe):-------------------------- <------' - € r .� .,� "'yr.a !� 1' " :. f ----------------- °-- € * -------- --------------------- -------- ---•- - x -------------------------------------------------------------------------- -------------------------- San m County ----------- t ------------------- -------------------------------------------------- ------•------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with 5 Joaquin ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. f r f (Signed)----D-i-fa------ " 'e ] -- , _-----_ _-(fid/or Contractor]- --------------------------------(Title (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). !,=y FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------- --- ----------------------- ------------ DATE REVIEWED BY---------------------------------- ----------- ----------------------- DATE -----------------------•--------------- BUILDING PERMIT ISSUED------------------- ------------------------------ ------------------------------- DATE ----------------------------------------- Alterations and/or recommendations:---.------------------------------------------- --------------------------------- y' -------------- -- ------------------------------•------------------------------ ------- FINAL 1NSP-CTION BY: - '' Date r i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South.American Street 3oo West Oak Street 132 Sycamore Street 814 North "C" Street ' Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M 8-51 Revised W-2100