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r APPLICATION FOR SANITATION PERMIT Permit No. tv .(Complete in Duplicate) 13,� Date Issued �.5 Application is hereby made o 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--------------- -- „� --- h �Zl -------------•--------------------------------------------------- Owner's Name ``. Z - y ----------- Phone ---- - ------------------------------------ Address-,--------------------- ----------------------- -----------------------------------------------------•------------- ---.---•------------------------------------- Contractor's Name -------- Phone ------------------------------ i Installation will serve:' Residence K Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ________ Number of bedrooms ,., IVumber of baths -------- Lot size ____._-___2- -•--_-t , r Water Supply: Public j system K Community,system,©.--Private ❑='"Depth to Wate able ________ ft. y Character of soil to a {depth of 3 feet: San d [❑ Gravel ❑ .Sandy Loam ❑ Clay Loam E] Clay E] Adobe Hardpan ❑ + IF i Previous Application Made: Yes ❑ No New Construction: Yes ❑ No y TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permittid if ptiblic sewer is available within 200 feet.), 11i: Septic Tank- Distance from nearest(well___:`.-.------------------Distance from foundation'---'--(.--)_____-__.Material__ ____________ _ -------------- -- No. 'of compartments-- .........1, ---Size____:�&17'9_• ------Liquid depth------� __.�--- Y Uacit Cap - Ln1 Di I Field: r Distance from nearest well--------- ____Distance from foundation------12- 1.__.-.Distance to nearest lot line-- 1--1 ine_--- .----- Number of lines----------- --Z--_---___Length of each line_ ---- 0 t- �`--�1 g ----5J.'_-- Width of trench------------ ------ Q TypJ of filter material / pepth of filter material____.__�tt� "____._Total lengthf-Qf�__--------- `n Seepage Pit: Distance to nearest wdll____ ----------------D.iitance from foundation______-1...-1------Distance to#nearest lot line_____..__-_-____ ■ x- ❑ Number of pits. - ., ri "mate�ial--------i----------.Size: Diameter Dept'rs Cesspool: Distance from nearest well_-________-_- - s� ante from foundation------------ -------Lining material-----------------.______---_______-__. ❑ Size Diameter-------------------------------------.JDeth Li uid Ca acit Liquid p Y --------------------------gals. , Privy: 'Distance from nearest well_______________ `_____T ----Distance from nearest building - � er r g------------------------------------------ ❑ Distance to nearest lot line ------------`-- { ,.. 1 ,� . Remodel`rg dd%o�rep0i6ffg (describe):---___S'__E_`__ '- ---------------------- -•-------•----•-------------------------- --------------- -----' ------)---•-------------------•----------------------- •-- --- -------------------------------------- ) It t,r �. --------------------------•---------------------------------------------•--------------------•------------------------------------- ------------------------- .I ----------------------------------------- ---------- - -------------------.------------I--------------------------•------------------------------------------------------------------------------- I hereby certify that I have prepared this application and` "hat to work wil be done in accordance with San Joaquin County ordinances, Sta"te Taws, nd rules and're ulation's.of the San Joaquin Local Healfh District. (Signed) At -- ------------------ V----------------------- -------------- ---------------------{Owner and/or Contractor) E By------------------------- :. -� 6� t (Titlel---- ----------------------------------------- ---------------- (Plat plan, showing size of lot, location of system in relafi n to wells, buildinps,'etL, can be placed on reverse side). F FOR DEPARTMENT USE ONLY +- DAT r APPLICATION ACC EPjED BY---------- r------ - E--- _" ~ = r REVIEWED BY----------------1 '` 1' r : -------S --- --------------- -------------- ---------------------------------- DATE = --- -------------------------------- BUILDING PERMIT ISSUED - f, -• ---------------------------------------- -1 DATE-------------- Alterations .A terations and/or recommendations:::__- - -- —. __�_._ _ k -------------------t-------.------------••; - '± • ------------------•--------------------------------- -------------- 1 ------------------------ -------•-•-------- -----------------•--------------------•------------------••-------------------------- -------------------------- ° - ----- - --------- FINAL INSPECTION BY----------------- �/ a `�'! �/�'I Date------------ SAN -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 10-52 Revised W-2100