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APPLICATION FOR SANITATION PERMIT=' = Permit No. (Complete 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 compliance with County Ordinance No. 544. _ Q JOBADDRESS AND LOCATION--`•------------------------------------------------ -•---------------------- ---------------------------------• --- - --- ----------------------------------- Owner's Name----------�--ss " -----. PhoneX_d Address---------- `-��cz�s-�.. -----------�---'"'e-{''""--------------------------------------------------------------------------------------------------------------------- Contractor's Name------------------------ ---------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence E-partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' 9 Number of living units: __/__Number of bedrooms __GZ_ Number of baths __/_ Lot size ---44.4-_'X_Z_ +d_J*--------------------- Water Supply: Public system [T-<ommunity system ❑ Private ❑ Depth to Water Table' II ft. t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑fl No EP—New Construction: Yes ❑ No �A/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted W lic sewer is available within 200 feet.) Q------Material0c4 � �C �----------- 19�Septic T k: Qistanca from nearest we -___�--__Distance from faundation___,� _ Capacity---$� No. of compart ments.....Gz----------------Size--.�i__Y-3-- ---- �gfrid depth--------4t __. -Q_- - Disposal ield: Distance from nearest well--------___Distance from ,ou,._ ' n---o- ---------Distance to nearest Io - Number of lines CPS _____________Length of ea{ lin =-___,3__Q_'__.Width of trenc _�.- '_,� �:. of filter material a _�C p of filter material_____—/_________Total length_______ ------------------------------- Type .Sr- '--De tfi Seepage at: Distance to nearest ell_ _______________Distan foundation__6-al ______-Distance to nearest lot line----�-____-_ � Number of pits -----------Lining material- _'k Diameter.__,'FJ_'V.......Depth____---------------- . Cesspool: Distance from nearest we]--------------_Distance from foundation-------------------.Lining material------------------------------------- 0 Size: Diameter---f----------------- --. ---------Depth--------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well---_---------------------------------------------Distance from nearest building--____--_--_-------_----___--____________- ❑ Distance to nearest lot line------- - ---------- !y Remodeling and/or r ainn ' { escrbe rr -------Z78 6)-----11 ----I'------------d - ------------------ r ---------------------------=---------------------------------------------------------- - I tify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinan 5, State aws, and rules and gulations of the San Joaquin Local Health District. (Signed)--------------- v" ___.-____- ___ ________ Owner and/or Contractor) By:. 4 -----------------------------(Title)-------- . - --r--------------------------------------- (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). k FOR DEPARTMENT USE ONLY t APPLICATION ACCEPTED BY--------�` ---------- -- -------•------------------------------- DATE-------------- ` REVIEWED BY------------- ------------------ DATE --------------- ----- 71- ---------•-- BUILDINGPERMIT ISSUED--------------'.-----------------------------------------------�-------------------------------------- DATE----------------------------------------------------•-------- -- ------ --------- - - Alter tions dor recce mendations:--------------_-.-.___ :L,-- -- ! _ a x s -----'- - - ------------- - --• -•--2- ---• --- .........----V - --- - --------------------- - - ------------ ------------- - - --•---• - ---- -- -•- -- -------- -�-.cam_ 1--- � - ---� ��--� -- - - --- -- -- c FINAL INSPECTION BY------- - ------ {� ----------- Date------ --3- -%��-------------------------------------- k SA JOAQUIN LOCAL HEALTH DISTRICT ' r . 130 South American Street 300 West Oak Street 132 Sycamore Streef-' 814 North "C" Street } Stockton, California I Lodi, California Manteca, California Tracy, California r. t ES-9-2M , Revisea 1-57 F.P.CO. t