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5 APPLICATION FOR SANITATION PERMIT Permit No. ` ....... 421 I (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 o. 549. 11 jj�� ,,,[r' ? .� JOB ADDRESS AND LOCATION --- LLVa M-------�C1_ ----------- ��P�'1 -�—/ ? V' Qwner's Name``---Lao---c;TQS�� s1#'4.17.9Oh---.... --------------- ---- --------------------------------------- Phone--2__?_�P_ l..... ^`Address- 44.------S... y�-----------------------------------------------------•---------------------------------------------------------------------------- ontractor's Name---------Jlill--�--d-------------••--------------------------------------------- Phone...hL�------------------- "' In Ilation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ 'Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ._3--- Number of baths _�At. Lot size __/ .; '` --------------------------------- .__0'W ________________________________ 7Choer Supply: Public system ❑ Community system ❑ Private Depth to Water Table -b-�_Q ft.cter of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ®'Clay ❑ Adobe❑ Hardpan ❑ us Application Made: Yes ❑ No [!I"' New Construction: Yes 0?-'No ❑ 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------ !�______Distance from foundation......10----------Material---------G'1'1t -------------------- 0 No. of compartments__.__-._-�.___----_-Size------sS7_X.9--7-3----Liquid depth-----_._ 41_ ----------Capacity.......Lr__�F ~ i Dispos Field: Distance from nearest well__.__�Q"4 Distance from foundation-.._2p__ . _.Distance to nearest lot line------- lines ___-_ Number of lines_______________ -:_ .____.__ _._.Length of each line_..______.q�___x �_.Width of french------- !�.a Type of filter material--------,_(y �____Depth of filter material--------1�!-_ g r -------Total length Pit; Distance to nearest well_____ ____ __________Distance from foundation--------------------Distance-Jo nearest lot line___._..-_.._____ ❑ Number of pits----------------------Lining material-----------------------Size: Diameter-----------------------Depth-.-----------_--•-----..-----_--- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material---._-__.__-___-_-__-___--_.--._.----. ❑ Size: Diameter-------------------------------------Depth----------------------------------------------------Liquid Capacity-.-----------------------.-gals. Privy: Distance from nearest well------------------------------_------------------Distance from nearest building------------------------------------------ 1-71 Distance to nearest lot line---------------------------------------------------------------•---•----_------------------------------------------------------------------ Remodeling and/or repairing (describe):------------------------------------------------------ •--------•------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- -- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 rules and regulations of the San Joaquin Local Health District. (Signed)-��=�- -U ; A! - (Owner and/or Contractor) (Title) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------- --------------------------------Y �----------------------------------------- DATE............................. y REVIEWED BY-------------------------------------------------- --------------------- - BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE-------------------_---------.............................. Alterations and/or recommendations----------------------------------------------------------------------------------------------------------------------•--------------........................ -------•------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------ --------------- ----------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------ ----------- ----------------------------------------------------------------------- ----------..----- ------------ -------------------------------------------------------------------------------------------------- .44 /l y� FINAL INSPECTION BY:-------- .r// ?-------------- 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 ES-9-2M 10-52 Revised W-2100