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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued`_ �Iq, 1 the San Joaquin Local Healfh District for a permit to construct and install the work herein described. Application is hereby made to This application is made in compliance with County Ordinance No. 549. Atre JOB ADDRESS AND LOCATION_ _______ ti.� _-- - - -- - -�-- Owner s Nam - .r.rLlre. r Phone---- ----- 3 d ------------------- Address----- -----c-n----=-------------•---f---�-,��-`--�"_'�`_.._-_..--(c-„,-�`-�-•----------� '`---�' ---------------------------------------- Phone.` � �' Contractors Name_--------------•----------- 811. K._ Installation will serve: Residence Apartment Mouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -___f_ Number of bedrooms -A- Number of baths ---I--- Lot size -_--47-'._vt------Z24!747------------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobel”, Hardpan ❑ Previous Application Made: Yes ❑ Noj�r_New Construction: Yes,��No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) • . C3.,. cl Material- ----------------- -----------�"---------- Se tic Tank: Distance from nearest well--- __Distance from foundation-- __C �� Septic No. of compartments-------�------------Size--c? .`� _ -"_Liquid depth------.�-----------Capacity--9-_--__--------- 00 3" Disposal Field: Distance from nearest weld--- �a� ._Distance from foundation-- .----_.Distance to nearest lot line---- _----. x Number oii lines------ -----y---�;----------Length of each line-------6---Q__--------width of trench.---•9_`^�-..............-•--- " - ------ '►� Type of filter material__-1_� _-L __Depth of filter material--.-.-_rt.- '_---.---_Total length--_- _ - Seepage Pit: Distance to nearest well---------------------Distance from foundation-------------------Distance to nearest lot line_-.--- ❑ ..G. Number of pits--------- -----------Lining material--------------------- Size: Diameter----------------- ----Depth-------------- Cesspool: ----- ----- ------------------ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material----- _---_----------------- als. ❑ - Depth _Liquid Capacity------------ ---------------g Size: Diameter------------------------- ------------ Privy: Distance from nearest well------------------------------------•------------Distance from nearest building----------------------- Distance ----------------- ----------------------•--------------- Distance to nearest of ane.-___.____________________________________ Remodeling and/or repairing (describe)---------------------- ----------------------------------------------•----- - -------------------•--•------------------------•-------------------------------------------------- --------- ------------------•-••-------------•-------•----•-------------------------------•---------•-----------•---------------------------•--------- -------------•------- I hereby certify that 1 hPrUles repared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, andand regulations-of the San Joaquin Local Health District. !�_ / __---..-_-._-_--(Owner ares!/.dr.Contractor) (Signed)--- -- - --- ---------- ---------- - - 1 .Cr.- Tale ��,�SY°�-�'�'_��-.--c.------ ---------------- -------------------- = �-.. -----{ )--- (Plot plan, showing size of lot, location of system in relation tof ells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ------------ - -- ----------•----------- DATE----- -------57_ —------------ ------------- --- DATE----------------- ------------------------------------------ REVIEWEDBY---------------------------- --------------- ------------ -------------- -------------- -------------- - BUILDING PERMIT ISSUED-------------------------- ------------- •----------- -------•-- -----•---------------------------- DATE--------------------------------------- ------ Alterations and/or recommendations--------------------------------------------.___-__.___-------__-_-- ---------------------------------- ------- ------------------------------------------------ -------- ---------------------------------------------------------••---•------------------------------•------------------------------------------- ---------------------------------------------•-------------------------------------------------------- ------------- ------- - - - - - - - - -- - ---------- -� 5-71e-- � �'• Date_.-.. !� --------------•------•----.-. FINAL INSPECTION BY_______________'------____--_- SAN JOAQUIN LOCAL HEALTH DISTRICT i3o South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California - Lodi, California Manteca, California Tracy, California ES-4-2M 10-52 Revised W-2100