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APPLICATION FOR SANITATION PERMIT Perrrfih No_ ___________________ (Complete in Duplicate) Date Issued y1 ; I �_?-3l/0-o,iro l 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. 1, JOB ADDRESS AND LOCATION "` ' E � `f7 .Y.-- --- ---------- ' t _ Owner's Name--•--------------- ------- �Cr Phone �- ys f ---- t Address 4. 'Q'e�-- T/u a-I`.t' Contractor's Name �� - - ✓? • -►�-6-.' Phone------F7 ,_-, a-7----- Installation will serve: Residence W Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: _/-___ Number of bedrooms __/-___ Number of baths ---/-. Lot size _____ --------------------- Water Supply: Public system ❑ Community system ❑ Private X Depth to Wafter Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam` Clay Loam- Clay ❑ Adobe ❑ Hardpan ❑ C-) Previous Application Made: Yes ❑ No W New Construction: Yes 4 No ❑ ' TYPE OF INSTALLATION AND SPECIFICATIONS: N (No septic tank or cesspool permitted if pylic sewer is available within 200 feet. Distance,frgm foundation__�p_____ __._.Material____�______-f_ �- ---- Septic Tank: Distance from nearest well_ ___ No. of compartments_____�--"---- Size�_3�_ `�--�---Liquid depth-----_o_�_.�-----------CapacitY----�Q�__ G�_a 63" r S Disposal Field: Distance from nearest well_ --___.Distance from foundation_�"D____________Distance to nearest lot Gne_________________ s s ei Number of lines-__1--------ij -- -- --- Length of each line_. _ __'- ----Width of trench------ -- --------------------- Type of filter material __ of filter material_48______________Total length---7,_`57.--------------------------- _Distance ----- ._Distance to nearest lot line----------------- Seepage ___________ -_ See a e Pit: Distance to nearest well_________________ - Distance from foundation--______________ El Number ofpits---------------"- ----Lining material-----------------------Size: Diameter-------•-____-- ----- DePth--------------------------------- Cesspool, --------___-- -__---- --Cesspool: Distance from nearest well-----------------Distance from foundation-------------------_Lining material___________-___________________._____- ❑ Size: Diameter------- --- --------------------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. f ,:� -.� ---- -- - - a fprivy: Distance from nearest well______-_________________________._____"_---_--_Distance from nearest building____---_____________________.--_________. ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------------------- Remodeling-and/or repairing (describe):------------------------------------------------ -------------------------------------------------------------------------------------------------------- I -------- ---�-- -� r --•--------------- -- ---------------------- --------------- --=--------------------- ----------11.------------------------ ----------------------- / - --- ------ .... .. --- .4)----- -�-------------------------------- �- ----- ---------------------------------------------- ------------- --...----------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County w ordinances, State laws, and rules �nd regulations of the ;�oaquin LocaHealth District. (Signed)--------� --f-------�WL--- --- --------- r --- Contractor ► ` --------------- BY: `� ---- - ---------------------------------------------------------------------- -----(Title) A� . (Plot plan ow' of lot, locatio of system in relation to wells, buildings, etc., can be pl, ced on reverse side). FOR DEPARTMENT USE ONLY # APPLICATION ACCEPTED BY--------------- -------------------------------------- DATE---------- REVIEWEDBY----------------------- -- -------------------------------- DATE------------------------------ ----------- ---------- BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alferaiions and/or recommendations------------- ------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------- - --------------------- --------------------------------------------------------" ------------------ -------------------------------- ------------------------------------ ------------------ ---------------------------------------------------------------------------------------------------------------------------------------------------------- - -- ------ ---------------- ----------------------------------------- FINAL INSPECTION BY:.-------- --- -------------- Data � � (%------------------------------------------------- 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 l ES-9-2M 8-51 Revised W-2100