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APPLICATION FOR SANITATION PERMIT Permit Noj)L ` (Complete in Duplicate) Date Issued __�!----�� Y A� 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. i JOBADDRESS AND LOCATION------------------------------------------------------------------------------------------------------------------------------- e -_ Phone-_..2" ----------- Owner's Name--- ltl��„?- ---- - Y---------------------------------------------------------------- - 1 --•------- " ------------------------------------------------------•-----•--- ---------------------•---- Address --r_�l.?.O_s2.._ reARc �- �O7 �••� � --. Phone--- --------- -------- --------- Contractor`s Name---- �_'---� ��;:_�`?- 1_ !> �----- Commercial Trailer Court ❑ Motel ❑. Other ❑ ---- Installation will serve: Residence 'apartment House ❑ ❑ � --Number of living units: -,l_--- Number of bedrooms _-J_ Number of baths -1_-__ Lot size _10-11_--,Jf--� Q-- i Water Supply: Public system Community system ❑ Private,.❑ Depth to Water Table ___ ff. Character of soil to a depth of 3 feet: Sand E] Gravel El Sandy Loam ❑ Clay Loam ❑ Clay E] Adobe ardpan El Previous Application Made: Yes ❑ �No New Construction: Yes No ❑ VI TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitter)lif-public sewer is available within 200 feet.) Septic Tank: Distance from nearest well [L _Distance from foundation-- Q--------Material_-- ��1 1I-------------------------- "1 No. of compartments-_ -- Size __--1�= Liquid depth_---�_0.-----------Capacity---9_---�A .2 ------ �l� ,G_.Distance•from foundation ---Distance to nearest lot line./-__-__-___ Disposal Field:: Distance from nearest we. Number of cines---------- ----- ---------------Length of each line-----------� ---------Width of trench----r�8 - E r Type or filter material__ o�i�"`_--Depth of filter material-_-��_�/_------Total length----- -_-___ _n-----------��- � E �i� Seepage Pit: Distance to nearest well_ -0 -_-_Distance from foundation_-__0P -_--...Distance to nearest lot line.._.___---- /� ,� E ®� Number of its----_ Lining materia / l�-•--- Size: Diameter_ r -------------Depth------- r ?----------------- p I --- --- 3 --------------------------------------- Cesspool: ___________ ° Cesspool: Distance from nearest well-----------------Distance from foundation -Li�nuid Capacity gals. ❑ Size: Diameter--l --------Depth--------------------- ---------- ---------------- q P y---- ------------------ Privy: Distance from nearest well-----------------------------------------------------------------------Distance from nearest building-------_--------------------------------- ❑ Distance to nearest lot IIr1E----------------------- --------- ----------------------------- ------- --------------------------------------------- ------------------ Remodeling and/or repairing (describe]:----__ - ---� bJ` � `'`�` f ` �_!__ __ ---•----------• -A ------------------------ ------•-- - 3._fir--------------------i---------•--•---------------------------------------------------------------•-------------------- ------ ----------------------------------------------------• hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I s, and rules and regulations of he"San Joaquin-Local Health District. J, ^ I ----------------------------------------------- weer and/or Contractor] (Signed}---------- - -�-�b ---------------------------------------------------------(Title)---- �-«t� X.r"� (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 --- DATE -- APPUCATION,ACCEPTED BY-_ _= DATE-- ------e-.�'-------- REVIEWED BY------------------------------ -- BUILDING PERMIT ISSUED-------- --------- --------------------------------------- -------- ----------------- DATE-- -- ----Ae------------------------------------------------------------------------- - Alterations ATE_ - ----'� e---------------------------------------- Alterations and/or recommendations--------------------------------------------------------------------------------------------- -------------------------- -------------------------- ------------------------------------------ -----•-------- -------- -------- --------- - DateJ--- FINAL INSPECTION BY:---------( --------- i k SAN JOAQUIN LOCAL HEALTH DISTRICT 300 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Street Trac California Stockton, California Lodi, California Manteca, California y ES-9-2M B-51 Revised W-2100