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APPLICATION FOR SANITATION PERMIT Permit No. ..lY__ s,T.._ \y +� TM� ' (Complete in Duplicate) y� <1 Date Issued ____�.�.�5: _:_ Applica-liontis hereby made'to',the San'Joaquin Local Health District for a permit to construct and install the work herein delbed. This application is made in compliance. with County Ordinance No. 549. 'JOB'ADDR-ESS AND OC TION_•---c2 /4--------- -- -- Owner's Name ------- --- -- Phone !f/ Address-----fes_R0-------- ---------------- ----- -------- -------------------- ---------------=------------=------------------------•-•----•- ----•---------------- Confrector's Name--t--,--- ---.. ---------------------------------- Phone- - ------------- Installation will serve: Residence Apartment House ❑ C.qrr`iercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of-living units: :-;;k: Number of bedrooms .2... Number of baths ___?4' Lot size ___�m afG ---------------------- ' Water Supply: Public system N 'Community'systeinr[]- []"` �.p to._WaterTable_ ft`—"°a' - Private' De th - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [l Clay'Loam o" Clay-❑—Adobe,M Hardpan ❑ Previous Application Made:'Yes ❑ N'o F .New Construction: YesX No ❑ r 1 1 TYPE OF INSTALLATION AND SPECIFICATIONS:,. # ' (No septic tank or cesspool permittedlf'public sewer is available within 700 feet.) 4e"Tank: _ Distance from'nearest} well-___...____-___:Distance from fo=undstion---:_------ ----.-Material----------------------- --------•-•----r----------- 4� No. of compartments__._. SLiquid depth________________________ Capacity...:__--_-_!--__-_____t Dispose► ,Field: . •Distance from nearest wr3ll 0 istance from foundation� _ Distance to nearest lot line_zw-------- c Number of lines_ __mom .---------- gth of each line--__4"G........ ----YWidth of trench-----,__-d/— 4--- ! " r �. Type or filter materlal �_1}O:�r 1, _.Depth of filter m teriaL_,_./ _ t Total length_ ___ _p----------------------------- s -----=-- ------------ -- Seepage Pit: Distance.to nearest well.. .�_ _ Distance from foundation_____ ! ____.Distance #o nearest lot line �_: ___ N mbr ois _ 'Liningf mateia -Size: Diameter---t ._ _ l --------- Cesspool: Distance from' nearest well-----------------'Distance from foundation____ ial---------------------------- El Si : Diameter----------------_-- -Depth--•-------------------:-------::--- --' Liquid Capacity ; gals. Privy; Distance ,rom nearest well _.Y� q__ ---_-_-.-- _.Distance from nearest building-----_ _--___:--____---------------- ❑ Distance'to'nearestlot l ne t= :--------- - ------- - - - - --------------------------- w _ = r. i Remodeling and/or'repaEring (descri`be):°----------=------ � - ' t ► , ----------------- ----------------------------------------- - - 1 .. T -- $ _ ` ' fi- _ ---j-- ----------------------- •---------- ;----------•--• ------------- -` - - LL -------------------------------------------------------- I --------------------- --------- I hereby certify that I have-prepared this application nd-fhat#he�work will be done;`in accordance with Sen Joaquin County ordinances, S a laws, and rules and regulat'ons of`the San,Jaaguin Local Health District. Si ned t _ — on t (Signed)---- A7 g ) C frac or) tf�� - - By:-------- size -- lot location s stem in relat (Title)- . _- ------- ._..'-- __.._.. (Plot ,plan, showing y ion to wells, buildings, etc., can be placed on reverse side). ` s FOR DEPARTMENT USE ONLY i , DATE - i - - ---------------- APPLICATION ACCEPTED 6Y ' REVIEWED i BY-----W-------------------------------------- ------------------------------------ ----------------------=------------------ DATE------------ ------------ ----------=---------- BUILDINGPERMIT ISSUED---------------- -------------------------= -`---------"-------- ------------------=--------=------ DATE---------------- =}----------------------------j-------- Alterationsand/or recommendations----------- -------------=---=------------ ----•--- --•-----------------•------•------•---W=---•-••--------- ----------..-------------------------------------- -------------------------------------- ------------_----------•-----••---••--------------•-_----•-----------------------_•-•----•------•--------•---_____-_ . ------------------ ---------------------- ------------------------------------I------------------------------------------------------------I-------------- ------------------------------------------------------------.-.-_----_-...___-_..-_-__-__----.-----_.---_--.-.-----_.____-_-_------.---..-----_____--------------------------------------------------------------------------- ---------------------------------- _ __ _ ------ - -- --- ----------- _-----_---------_-_--____._. --------------------------------- FINAL...INSPECTION-BY:- = =" _ Date_--� moi. .� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Stroef 132 Sycamore Street 814 Norfh "C" Sfreef Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Revised W-2100