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APPLICATION FOR SANITATION PERMIT Permit No. ...-' -�.0_-. jComplefe in Duplicate) Date Issued ----•------------------ - 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.co-compliance with County Ordinance No. 549. JOB ADDRESS ANWLOCATION----------------3 5-31,sl0O / -------------------------------- Owner's Name-------------k-----_ ' �� = Phone --------------- Address----------- -------------------------------- ------- -------------------------------------- -------------------------- Contractor's Name---------------------------- -------- ---------------------------------------- ----------- Phone -------------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ y ❑ Communit 1%stem private of baths f.-__ Lot size ._-_--"-. - "- ,Dd Number of living units: -------- Number f bedrooms _ --- Number Water Supply: Publics stem y y ❑ K Depth to Water Table _X' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ) New Construction: Yes, No ❑ ' TYPE OF INSTALLATION AND SPECIFICATI �NS: R" +'�N (No septic tank or cesspool permitted if public sewer .is available within 200 feet.) Septic Tank: Distance from nearest well------SII__-----Distance from,founclation----1Q-------------Material ----_------Adcw No. of compartments--.----____2`--__N---Size----- ------Liquid depth--__----.'1y" Sd '-------- Capacity---•--�----- Dis Field; Distance from nearest well_-". ._Distance from foundation--------------------Distance to nearest lot line----------------- ., Number of lines-----------------------------------Length of each line...............................Width of trenchtW --------------"""-- Type or filter material-------------------------Depth of filter material--------- ----------------Total length------------------------------------------ Seepage Pit: Distance to nearest welt----------------------Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits----------------------Lining material!:.......... ----------Size: Diameter.......... 777"=---- Depth------------------------- ' 14,41, Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lin ngImaterial----------------------- ,- ❑ Size: Diameter--------------------------------------Depth--------- ;=-)---------------------------------------Liquid Capacity--------------------------.gals. Privy: . Distance from nearest.well._.: —:-_-_"..:-,---"-- ----------------Distance from nearest building ❑ Distance to nearest lot line------------------ - "r 7------------------------------------------------------------------- Remodeling and/or repairing (describe):----------------------------------!S )Q - -4--•- lzr Kv-," �2 --"---------•-•------"--"-------"----------------- ' ------------?rte--%�l_.---�---------� -��-'--------d''1=-------�---------� --- - - --------------------"-------------------"•------------------- --------------------``,kcy/'-----�� rn� ---------------------------------------•-------- ------------ ... =-----..-..--------------------•--------------------------------------------------I-----•- «.� - 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)---- --------------------(Owner and/or Contractor) By: (T-- i+le)--------------------------------------------- Pot plan, showing a of lot, location of system in relation to wells;•buildings,.etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- ----------------------- - ----- DATE-------------- REVIEWEDBY------------------------------------------------------------------------- --------------- DATE----- ----- IN PERMIT ISSUED------_------------------- ------------ --------------------- DATE------' --- -------------------------------- Alterations and/or recommendations----------------------------------------- --------------------------------------------------------------------------- -----------------------------------------------------------------------------------------------------------•-------•------•-------- -----------------------------------------------Date_ - a-------------------- -------- FINAL INSPECTION BY---------------------- r .- t . te - ' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M to-52 Revised W-2100