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1 APPLICATION FOR SANITATION PERMIT Permit No. "-_... ii5 '} (Complete in Duplicate) ( 0 Date Issuedation is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. pplication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND rLOCATION---------9--'21-z------- '----------------------------------------------------------------------------------------------------------- Owner's Name _ . •." ..- ---------------------------------------------- -------------------------------- --- - Phoney 44?_T_il------------ Address---------' ls------- '-- ------`- �-up Phone ��.11 Contractor's Name". 1214 - - Installation will serve: Residence F Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: """�""" Number of bedrooms _"a`. Number of baths -"l""" Lot size _"_3_-a "X� ------------------------------------- Wafer - ------------------------_.-_Water Supply: Public' system 0 Community system ❑ Private ❑ Depth to Water Table yv- ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑, Adobe 21 Hardpan ❑ Previous Application Made: Yes ❑ No R] New Construction: Yes W 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-MP WW/ WIL_Distance'fromNfoundation ---2-°-. Materia --- Capacity""-�---�--b------�-_- _- ��l No. of compartments-------- ------------ -- KLiquid depth------- _"".".""" pisp�al Field: Distance from nearest we,I:N►. eI�"Distancefrom to nearest lot line""----"""---"""""-.""" Number . of lines-------- -------------------------Length of each line---3°-----------------.-.Width of trench___�"y"_."""""".""""."-_-""--• ` Type of filter material"s'0!;:lf--------Depth of filter material----. Z..........Total length----3°/---.---_-------------------- Seepage Pit: Distance to nearest well_2� ."Cr A---Distance from foundation""" ------------.Distance to nearest lot line--.-------------- Number of pits------1-------------Lining material- ___Size: Diameter-------3.6 _----_.Depth......---.---.---------.- Cesspool: Distance from nearest well-----------------Distance from foundation.-------------------Lining material_--.-------------_----_-------------- . ❑ Size: Diameter------------------------------------ Depth---------r-----------------------------------------Liquid Capacity-_------------------- ----gals, Privy: Distance from nearest well-----------_------------------------------------Distance from nearest building---------------------------------- ❑ Distance to nearest lot line------------------------- ---------------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------- ------------------------------------------------------------------------- ---------------------".---------------------------------------------------------------------------------------------------------------------------.....--------------------------------------------------• ------------------ - -- ---------------------- ------- -----------------------------------------•--------------------------------------------------•---------••------------------------------------------------------------------------------ I hereby certify the+ 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. Y (Signed) -------------------------------------------------------------------------- �wner and/or Contractor By:---------f3L.U___4)_A44�--------- ---------------------------------------------- Title ' ------------ ------- (Plot plan, showing size of lot, lots n of system in relation to wells, buildings, etc., can be placed on reverse side). } 3 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------------------- - j DATE - (� REVIEWED BY --------------------- --- `.' - --- --------- DATE -------------------------------------------- BUILDING PERMIT ISSUED---------------------------------- -----------------------------------------------------•------------ DATE------------------------------------------ -------•----------- Alterations and/or recommendations---------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------ ----•----••--•--•------;---•----•-•-•. ...._.----I- -•----------------------------- ------------ -----•-- •---•• ---------- •---• --•--- -------------•---------------"----------------------------- ---------------------I---------------------------------------------------------------------------------------------------------------- ------------ ------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------- --------------------------------------------------------------------- -------------------------------------------•---------------------------------------�------------------------------------------------------------------ t FINAL INSPECTION BY: f 1 J { = v; ------------------- ------------ date p � - r SAN JOAQUIN LOCAL HEALTH DISTRICT 130 Soufh American Sfree+ 300 West Oak Siree+ 132 Sycamore Sfree+ 814 N "C" Sfreef EStock+on, California Lodi, California Man+eca, California Tracy, California ES-9-2M 10-52 Revised W-2100 {