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J APPLICATION FOR SANITATION PERMIT Permit No. ----.--.-- + (Complefe.in Duplicafe), ►t# 41 Date Issued -------- ..-- l Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work`herein described. f This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA%ON------------ ; ------------k ---------- _--L- -------------------------------------------------•--------------------------------- Owner's Name---------------- � ---- ---• --I. ------- ----------------------------------------- Phone ---------------------------------- EAddress----------------------------------------------------•-----••------ Contractor's Name.. - ••-------------•---•----•--------------------------------------------------------------------------------------------- Phone----------------------------------- Installation will serve: Residence Z3-�Partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---/--- Numbebedrooms -2-.- Number of baths __1-. Lot size _---__L}-'+ ---&J-_•�__0----------------------- Water Supply: Public system ommunity system ❑W 'Private E] Depth to Water Table -------- ft. F Character of soil to a depth of 3 fest: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe J4--1-1-6rdpan ❑ Previous Application Made: Yes ❑ No &4- `New Construction: Yes(Lj--Ne-❑- r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-(f)CaDistance fro foundation_-__.J Q-�-----Material_____ r, -V�t- 7 , K No. of compartments--.------�,I ...--Size-- _-_ -. -- .��_Liquid de th---- ---- f Disposal Field: Distance from nearest well- �2°�_60',.Distance from foundation--__. ?/-----Distance to nearest lot line---"S1__. PNumber of lines-----------/---------------------Length of each line---------7--`�_-_'�___c.Width of trench-------lr74_f`--..__-- i Type of filter material_ -__ -_-Depth of filter material----)-8--------_--Total length-___,-7 s------.._______--.__---_-_ Seepage Pit: Distance to nearest well----------------------Distance-from foundation---------------------Distance to nearest lot line----------------- 171 Number of pits----------------------Lining material----------------------.Size: Diameter------------------. -Depth----------------------_----------- Cesspool: Distance from nearest we1L----------------Disfance from foundation-----------.__.----.Lining material--..--_.._.__-._---.-----.___.-__--- ❑ Size. Diameter Depth------------------- �� prrLiquidCapaci.tY -------------------- `=gal . . . Priv �� Distance from nearest yell ---__ Distance from nearest buildm y' g----. --------------------------------- ❑ Distance to nearest lot line--------------------------------- -t. ; Remodelingand/or repairing (describe)----------------------------------=--------------------------------------------------------------- -=----------`---------------------------------------- i --------------•--------..------------------------------------'-------------•-------•-----------------------------------------------•-•----------------------------------------------•-------•- ---------------------------- ------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------i_-_--- -_--.-------.__-.----------._-_-_--.- f ` I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Iordinances, State la , and rules and regulations of the San Joaquin Local Health District. b qsyvsft (Signed}- ------------ -- . ..---- ..-_. _ ---------------------------------(Owner and/or Contractor) lB -----------------•----------------•-•- -------------------------------------------------------------------(Title)------------------- t------------------------------------------- (Plot plan, showing size of lot, location oin relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ! APPLICATION ACCEPTED BY----------- --------------------- ----- -----------k----------------------------------------- DATE------ I `�J rsREVIEWED BY----------------------------------------------------------------------------------------------------------------------------- DATE BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------------------------------•---•------- ' Alterations and/or"commendations: --.---.-. - �— li , f � - �� ------------------------ ;;,"r - ------ ----- -----------X=-A------------ --------- -- -- --- - --- -- ------- ---I X FINAL INSPECTION BY -�_ Date...-- ' -- ------ ----- J� &N .! CAr 1--1E ZTH DISTRICT 130 Soufh American Sfreef 300 W'esf Oak Sfre 132 Sycamore Sfreef -914 Norfh "C" Sfreet Stockton,,California Lodi, California Manteca, California Tracy, California ES=9-2M 10-52 Revised W-2100 a