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or APPLICATION FOR SANITATION PERMIT Permit No. ... 1.. _ ____-.-_ (Complete in Duplicate) I'r Date Issued Applica4-ion 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. 173 --- OS'a—f f JOB ADDRESS ANDLOCATION--- /./S i '/ ( __ f P�Ls_.-_-•©/--.r_ A�!`/��S_r.-_/�fk�_..---- Owner's Name---------�Mrk=----,/-S�j�/`/a__-j7---------------------------- --------- ------- ------ Phone--- ••------------------------------ Address-------------------------------•---------------------------------------•------------- Contractor's Name----------x4rr ------------------- Phone..---------------------- Installation will serve: Residence J�'Apartment House ❑ Commercial ❑ Trailer Court ❑/ Motel ❑ Other ❑ Number of living units: __l•-- Number of bedrooms-_ Number of baths/. Lot size �P�_., .__. ,_ ____________________________ ; IF Water Supply: Public system 'Community system ❑ Private ❑ Depth to Water Table ft. c Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay-❑ Adobe WlHordpan ❑ Previous Application Made: Yes 0 No ®" New Construction: Yes R�"No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) A� OD Septic Tank: Distance from nearest well_I!' 'Ad'Disfance horn foundation--- —--------Matti l ---'L _. s f1---------. -- No. of compartments..... -----------------Size--- .lE%_. _'jC ___Liquid depth__..." Capacity.__ :, --- - - -------- Disposal Field: Distance from nearest well,41041�_Distance from foundation___ a .....Distance to nearest lot line._,lDr'3 ��' Number of lines--------/----- ---- Length of each line.----� �---. .Width of french._.__.Pv�v ----------------- Type or filter material _ZAP_�.CDepth of filter material--_lt.._-.___._Total length------ '-_________________.._.._or 2— Seepage Pit: Distance to nearest well...., /j&&'!_Disfance from foun ation__-_,C-+ __ _ ._-_.Distance to nearest lot line � 19 Number of pits___----/---_-______.Lining material_jfe� Size: Diameter _ .e __- ...__.____Depth Cesspool: Distance from nearest well_________________Distance from foundation-. .... ...... Lining material_____.._--_.--___._._________-_______. �yf ❑ Size: Diameter----------------- -------__-------Depth---------------------------------------------------Liquid Capacity---------------------• ---..go s. Privy: Distance from nearest well---------------------------------- --------------Distance from nearest building--------____________-_•__________..______. ❑ Distance to nearest lot line----- - --------------------•----------------------------------••------------------------- --------------------------••------------- ------ Remodeling and/or repairing (describe):------ t------------- ------------------ ... ----------------------------------------------------------------------- +� 4 _____------------I---------------- ____---------------------_--------------------------------------------------------------------_------- ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ A 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, and rules and regulations of the San Joaquin Local Health District. ' � '�- . (Signed)---------------- - -- ---------- - -• •-- - - - -- -- - - -,-- - --- -- -- ------------------------------------------------(OwFw4amed0or Contractor) R By:_..............._........... -•-- •.... �� -------- ---------------------------(Title)----`'.�---� .... ----.-.. � (Plot plan, showing size of I ocation of system in relation to wells, buildings, etc., can be placed on reverse Me). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED Bf7�-------------------------------------------------------------------- DATE---- ---------- ---------------------------- REVIEWEDBY------------------------------------- ----------- -- --------------------------------------------- ---------------------- DATE------------- BUILDING PERMIT ISSUED-------------------------- ------ DATE--------------••--e',f ---•-----•------ Alterations and/or recommendations:------- ------------ - - ------- ------------ -----••---••------------------------------ ------•----------•------------• ------.------------------- --------------------------------------------------..... •------------------- ------------------------- ----------------------------......-----------------------------------------------•-•--•----------------------------- ----------------------------------------------------------------------------- -----•----•-----------------------•----• ----- •----------------- - - ----------------------- ------------ -----------------------------------.------ ---------•- ------------------------------------------------------ ----------------------------•--•---------------------------•---------- 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, California ES-9 145446 ATWOOO • 4