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r A ICATION FOR SANITATION PER) Permit No. --------_ { [Complete in Duplicate) S Co Date Issued . /Jz___.�,� Application is hereby made to the San Joaquin Local Health District for a permit to construct and instal;the work herein described. is application is made in compliance with County Ordinance No. 549. r. ' f/ ------------------------- ------------------------------ ----a 4 --------------------------- JOB ADDRESS ANCA, L�TION___-_ . � . • -i Owners Name------ a ; '" ° Ph ne_ � Address- • ----}� y -----------• ------ Contractor's Name------- .--- ----- -------------------------------------------- Phone- Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court AMotel ❑ Other ❑ Number of living units: o2_-__ Number of bedrooms -o2-- Number of baths J___ Lot size -_;00 _X-1111r49 Water Supply: Public system Community system ❑, Private F-1 'Depth to Water Table_ ft. Character of soil to a depth of 3 feet: Sand ElGravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ' Hardpan ❑ Previous Application Made: Yes ❑ NoX New Construction: YesX Nor❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 5 Se •c Tank: Distance from nearest well_______________Distance from foundation_---______________.Materiai----------------______-____-_______----__-_---- - x No. of compartments-- -----------------------Size--------------------------------Liquid depth---------- ------------Capacity--------------------- pis o�Fiip� : Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line_______-___-____- �A Number of lines------- ------------------Length of each line------------------------------Width of trench----------------------------------- Type os` filter material_________________________Depth of filter material-----------------------Total length___-______________--________-_____-___---. Seepage Pit: Distance to nearest well- _____Distance from oundation____-hv- -____.Distance to nearest lot line_f__,j5_'____ ~��------- Size: Diameter ©� Depth----:-`�-------- ------ Number of pits___.__-�_______-___Lining materia�`9 � - --- esspool: Distance from nearest well-----------------Distance from foundation--------------------Lining materia;_________'________----------_-______. W ❑ Size: Diameter--- -------------------------------- -Depth---------------------------------------------------Liquid Capacity- --------------------------gals. i "Pr Privy: Distance from nearest well----------_______--------------------.-----------Distance from nearest building--------------.---- .--________-_-_-__.___. 1 ❑ Distance to nearest lot line---------------------- -------------------------•---------------•---------- �-------------- ---------- b �fyi --Mme----- '�-------•--•--------- Remodeling and/or repairing 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 rul s pd regulations ofghe San Joaquin Local Health District. u �- +� , :rr'C{' [Owner and/or Contractor] (Signed. • _ -- ,f . + Y• (✓-f (Plot plan, sh in size of Flo , lo of system in relation to wells, buildings, etc., can be placed on rev se side). i FOR DEPARTMENT USE ONLY - APPLICATION ACCEPTED BY--- --------------- ---------------------------------------- DATE-------------- ! - 7------------------------- REVIEWED BY - - DATE- �J BUILDING PERMIT ISSUED DATE ' Alterations amd/or . c miSnenda,#ions __. _ r � - __ ----------- --------------- ---------------- �, r rf - _ _------ -R -( ! - --------------------------------- ---� ------------ - RNAL INSPECTION BY:-- -----" 9 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 E5-9-21vi 10-52 Revised W-2100