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L APPLICATION FOR SANITATION PERMIT Permit No.t s (Complete in Duplicate) ____---- 0.5 Date Issued pplica�ion is hereby made to the San Joaquin Loctijal Health District for a pee it to construct and install the work heWin described This application is made in compliance with County Ord' ante No: 549. JOB ADDRESS AND LOCAT€ON_ _ .+<`�f_ . a.. [. . .-� -- - ---- ---------- i�- :. )------------------ Phone__ ....5?J q_ i -- -------------------------------------------- Address ---%_ r_G- ---- Contractor's Name------------------------- ------------------------------Z:S--rca----------------------- Phone `19-60--7-� Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailed C�❑ Motel ❑ Other Number of living units: -------- Number of bedrooms -------- Number of baths __`Lot size___�_________�_�S' Water Supply: -Public system ❑ Community system ❑ Private%I Depth to Water Table j ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe❑ HardpanZ�, Previous Application Made: Yesj!j_blo ❑ New Construction: Yes'g,,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 wellAtP_ Distance from foundation__ D"--______.Vaterial__ '��e------------------. No. of compartments--- -------------------Size_.v,—b_ __4-b'"�__Liquid depth__- __0-------------.Capacity_!-9_Xv.�44 .� v 4 Disposal Field: Distance from nearest well-_— ---Distance from touF�clation___/S"_- __.Distance to nearest lot line______:== NNumber of lines__-Y__'"t t:"_--- -----Length of each line-- -r'__-----�-----.Width of trench_._�_�"_'--------------- T e of filter materFal._ _ __ r.,--Depth of filter materialTotal len th___ � __ _____________________ --------- Type 9 Seepage Pit: Distance to nearest well___' _"-_Distance fr m f undation� ___.Distance to nearest lot lne_____�_ Number of pits--- /____________Lining material_`/`___--Size: Diameter._��-__.____Depth-/_?_" __70 Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-----------------------------___ Size. --- SiDiameter------------------ -------- ---- -Depth- ------ ------------- -- - ----- -• . Liquid .Capacity- - -----------------------gals. - - _❑ •- -�.a-•-. .. .rte .-------- -..----. . :..---. ,.:..�_r�---_------_--I-- �-- - . - �-.-__ . .- Privy: Distance from nearest well ______------------------------------------------Distance-from nearest building--------------------------------_--------- " LL ❑ Distance to•nearest.lot line------------------------------- _. Remodeling and/or repairing [descri e):_____ __...____1"___ ------------- ----------.�,c�, a.._ r ---- . ----- ------ -- --------------- --------------- "_ ------------ fir, ------P------- -t - --- - --------------------- ---------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws-.--a-nd-rules and regulations of the San Joaquin Local Health District. i (Signed]--- / (�r;Contractor] ---------------------- - ` ---- B ------------------------------. --------------- °, ,U1. _I�yl1!4. _-.(Title /SAS _ �- r_ �t�,r- ------------- [Plot plan, showing size of lot, location of system m relatio tow IIS 'Idings, etc�'ean be placed on reverse side]. ' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- - = r-- .� -------- ------ DATE _. -------------------- REVIEWED BY ------------ ------------ ------- DATE -------------------------------- BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE---------------------------------------------- -------------- -- -•----------- Alterations and/of recommendations:_____________________________._ - ---------------------------•-----------------------------•---------------------- ----------------------------------------------------------------------- --•---------• ----- ---- ._... .._._----•-•-------- -------------------------------------------------------------•--------------------- -----------------•----------------------------------------------------------------------•-•---•---------------------------------------- ------------------------------------ - -- -------------- --- -- ------------------------------------- SAN FINAL INSPECTION BY---- - -- ---- --------------------------- -- -------------- Date.----------- 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, C fifornia i 1 E5-4-2M Revised W-2100 - "