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APPLICATION FOR SANITATION PERMIT Permit Noc. p__�___�_.... (Complete in Duplicate) f Date Issued Applica+ion is hereby made to the San Joaquin L6cal Health District for a permit to construct and install the work herein described. This applicafion:is made;in compliance with County Ordinance No. 549. ; s JOB ADDRESS AND LOCATION---`_ 07 "fh✓ � 0 ------ - } Owner's Name.---' " _ ----- Phon (7... y Address-_.........__----------•--------------------- .. ... -�- '.&"519 � -------•-•- ------- .. �] �----- - 6KU Contractor's Name -•------•------••--JL=...l�: r Is = Phonj Installation will serve: }Residence. )& Apartment House '❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms __Number of baths ._/__ Lof:size ____ '47V -4-m-_._'--------------- 1 Water'Supply: Public system Community system "-Private ❑ -Depth to-Water Table oil ft. Character of soil to a depth of 3 feet: � ❑Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ �dobe Hardpan ❑ Previous Application Made:- Yes,E] No New Construction: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi Tank: Distance from nearest weil_ Q��Distance from foundation_tQ______'____.Material__ --------------- ------- ______ f No of compartments__Z__________________Size_,'�'"�t�'. N3 q p. *+ p Y-- _ ..___,_•Li Liquid de th_ _____________Ca Capacity-- "10 Disposal Field: Distance from nearest well "__._Distance from f6undafion_/Iz-____".__.Distance to nearest lot line..... Nuimber+of-lines____________________.----__.____`Length of each line_ -------------------Width of trench ._ Type of.filfer material______________________IDepth of filter material____.________;________Total length_ ... r�,.e.�.. ... '. _ 0 v e Seepage Pit: Distance to nearest well' Distance fr m f undation_� ________.-..Qistance to neares /�of line____ Number,of pits----�---- -----------Lining material ---.Size: Diarimefer__. - -_--__ --Depth__ - -_.-__------__- -- Cesspool: Distance'fi=om nearesf well----------------- Distance from foundation____. ------_------Lining material----------------___________________- W �: ❑ Size: Diameter-------------------------------------Depth-----------•--- -------•---------------------------Liquid Capacity---------------------------gals. J� _ a Privy: Distance from nearest wyell-----_----------------------------._----_-_-_k-.Distance from nearest building__._----------------------.------------ rr7 Y ❑ Distance-to nearest'Jot:line--=---------------------------------------------` Remodeling and/or repairing[descr.ibe)t- ------ --------------------------------•-------•-----------------------------------••---•- - : I ! - t ' -----------------------------"----••-------------------------------- - --------- ----•-----------------------------•---------------------•-------------------------•--•------•-------•-------•--"-----------------------------------• -- =--------------------•------------------- -------- &+ I ----------------------- --- ` -----•--------•--•---•--------•---•--------------- V ! hereby certifye prep ed Phis p kation and that +he vrork wi I be done in accordance with San Joaquin Coun+y ordinances, Stafe laes and a uIatio �, f +he San quin Local H lth Districf. Si ned -• -- -- .,i-v '- ------- -- --- - - ------------------------ s..COt�tractor } 7. -------------------- r BY=--------------------------------------------------� - - ----- - - - --- - -- --- -----(Title -- --- -- - - ---=`� ------ i (Plot plan, showing size of lot, locafion of system in rel io wells, buildings, c., can be p ced on reverse. side). s- FOR DEPARTMENT USE ONLY ,�PPLI,CATION ACCEPT--ED,,BY- =-- -------------=- ------- --=ti-------- DATE---------- � �. ---------- rREVIEWED BY-----------=--- .--------- ------ --------- ----------- : t, -- - --- -- DATE----------------------------------------- ------------------ BUILDING PERMIT, ISSUED---`--- ---------_--- ` =``= ---� = = DATE -Al+era+ions and/or recommendations:--- ----------------------------------• -----------------------------------------=-----------•--------------------------------------------------------- t ----------- -----------I---- ------ ----------••-------•-•--------------------.----------- ------------------------------•----------------•-•-----•-•- •--------- -------------------------•---------------------------------------•------------------------------------•-------------------•-•-......__-------- ._.. I t I: .. , - i ---------------------------------------------------•---•----------------------------=--------------------------------------------------------------------------------------------------------------------------------------- 1 - } f FINAL-INSPE&ION-BY...-• -- .- = ._ Date----- - "== -------- SAN JOAQUIN LOCAL HEALTH DISTRICT , o 130 Soufh American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Sireef Stockton, California Lade, California Manteca, California Tracy, California ES-9-2M Revised W-2100