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APPLICATION FOR SANITATION PERMIT Permit PTA �" � ' (Complete in Duplicate) � • +-11 !fi n � Ne .� ' ss d7� Applica�ion is hereEry maVVdelY'to the San Joaquin Local Health District for a perm ,o ct and install the work he i4,Aib.j. This application is made in compliance with County Ordinance No. 549. t/ / / JOB ADDRESS AND 'LOCATION--- --- OCATI N_ 0- _ ---- --------- ------------ --- Owner's Name---- •-� j rL__ 1 ! ----- - ---------------------------- ----- Address--- 3 ... -G'?�!i''4------------------ --------•-----------------•----••------------------------------------- ---= '�•.a Contractor's Name--------- - --- L- - Phone--/�..`t _G----.----- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ,EJ -Motel ❑ Other ❑ 1 1 /�'X y�--------------------- Water ---'---- - ~ r � Number of living units: __ ____ Number of bedrooms ___ __ Number of baths -_ ____ Lot size _________________ . - Water Supply: Public system ❑ Community system ❑ Private [R--Depth to Water Table 3'S ft ,.�. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [] Clay Loam ❑ Clay ❑ Adobe 94--<ardp8rrfl Previous Application Made: Yes ❑ No 2--_&w Construction: Yes 2"No ❑ � TYPE OF INSTALLATION AND SPECIFICATIONS: " -[No septic tank or cesspool permitted if public sewer is available within 200 feet.) c + Septic Tan Distance from nearest well___,�?-------Distance from f/o�unation_1 _..____..Mat_erial------- ___._______- e ��_ 1Ar Liquid de th______ _y ______Ca acity �No. of com artnents_..__ 7 a Disposal F' d: Distance from nearest well-- S�_........Distance from foundation:_-�, - ".�--.Distance to nearest lot line__e ' --_-___� Number.of lines-------= a�r-------- ---- -- Length of each line f__ -`�---/___--.Width of trench--=:_,il- ��----------------- Type of filter material_s S__, � __Depth of filter material______/_ __________Total length_______,l_ _ ---------------------- Seepage --- -Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest I.ot line____-..._-._---_ , ,❑ -., ti Number of pits-----------•---------.Lining material-----------------------Size: Diameter------------------------Depth---------------------------____--- .r Cesspool: Distance from nearest welL________________Distance from foundation----------_---------Lining material__.____._________________._.___.__ ❑. �' Size: Diameter-------------------------------------Depth- --------------------- r-----------------------Liquid Capacity-----------------------------gals. x Privy: Distance from nearest well-------------------------------------------------Distance from nearest building.__.___.______.______-____________-_____. ❑ Distance to nearest lot line_________________________ �. . Remodeling and/or repairing (descri�e):-----------------------------------------------------------------------------------------------•-------------------------------.----------------------- -----------------------------------------------------------------------------------------------------------•------•------•-------------------------•-•----------------------------•---•----------------------------------- -------------------------------r------------- -----•-------------•-----------------------•-•---------------- ------•------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun , ordinances, State laws, and rules and regulations of the-San--Joaquin-Local Health District. _9-Ab .--_ �"�-e'`''_________._ Owner and/or Contractor (Signed)------ - - [f ) ------R $y:------------------ � --- ------------------------------------------- ------------- '{TitEe� I- (Plot plan, showing size of lot, location of:?. ystem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED BY----- -- ,--_Av w-m-r Viz✓ e ------------------- DATE------ ------------------------------- a REVIEWED BY-------•--------------------------------------"----- ----/--------------------------------------I------------------------- DATE---------------------------------------------------••------- ..� BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-----------------------------------------------------------• Alterations and/or recommendations----------------------------------------------------------- -----•-------•------•------•------...----------------------------------------------------- ---------------------------------------------------------------------------------------------------- -----------------------------------------------------------------------------••-•--------•--------------------•----•----- -----•--------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------- --------•------------------------------------------•------------ --------------------------------------------------------- •------------------------------------------------------- ----------------- q - 12- —Jed FINAL INSPECTION BY:----- = `�------ - �--_------------- Date----------- -------------•-----------•---------------.----•-----------•-••- x SAN JOAQUIN LOCAL HEALTH DISTRICT . 130 South American Street 300 West Oak Street 132 Sycamore Street 114 North "C" Street Stockton, California Y Lodi, California Manteca, California i Tracy, California } = f f ES-9-2M Revised W-2100 �,