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r F APPLICATION FOR SANITATION PERMIT Permit No. ........................ A Z , (Complete in Duplicate) Date Issued Application is here y made to the San Joaquin Local Health District for aspermit to construct and.-Install the work herein described. This application is made in compliance with County Ordinance No. 549: JOB ADDRESS AND LOCATION----y-�----,------�8. �---------w-----------f -ive ire----}---- . Ape i Owners NameVr. = --------------- Phone Address------------------------------------- 941-------- --- `Rs"-------- ; Contractor's Name---------------•-------.--------- - Installation will serve: Residence � Apartment Hawse- ------------ - -- ------------------------------------------------------- Phone-.---------------------------....-- p tF] Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ; Number of living units: -------- Number of bedroo s,..�,2. Number of baths ------ Lot size ----------$70..'X J.g0- ----------- -- - Water Supply: Public system ❑ Community system ,® Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑f,$,pndy Loam ❑ Clay Loam ❑ Clay ❑ Adobe qZ Hardpan ❑ Previous Application Made: Yes ❑ No, New Cons ] ruction: Yes, ] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 11 septic tank or cesspool permitted if public st— (Nor%if. aivailable within 200 feet.) / Septic Tank: Distance from nearest well..-.--_"----Distance from foundation-------0--------Material-.------___ �__------------- rim' compartments # 's °---Liquid del fh---------4/ t..--- . Capacity------No. of ___-...-....)--.----.-Size4..._..._- X_ r Disposal Field: Distance from nearest well- --"-----'Distance from foundation____..-�4..-----Distance to nearest lot line......-.._.. 00, Number of lines--------------Z.,.. .1 Length of each line----1flc?-�..-.i-0,.. Width of trench.......... `1- Type of filter material_+__-----Rj 1,0" _depth of�filter material.......-,l length--__.-..-.1�,/1.............._--- Seepage Pit: Distance to nearest well----------------------Distance from foundation------------------- Distance to nearest lot line..--------.-----_ ❑ Number of pits----------------------Lining material------k---------------Size: Diameter-----------------------Depth-------------.------------------_ Cesspool: Distance from nearest we}l-----------------Distance from foundation._.-------------- Lining material--------------- Size: Diameter--------------------------------------Depth-------f------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest wlielk.� .�.��_-'--- -------------Distance from nearest building-.______......._....--__....._---------.. ❑ -------- ------------.'�..' , Distance to nearest lot ne___-.-.._................. __..-__.._ ---------------t Remodelingand/or repairing (descr';&)----------------------------------------------------------------------------••-------------------- -------------------------------•------------------- 7 -----------------•-••-----••------•--•--------I-•---------•------------------ ----------•----------------------•-•---------------- t + I hereby certify that I have prepared this application and that the work will 6e done in accordance with San Joaquin County ordinances, State laws, and rules and, regulations of the San Joaquin Local Health District. (Signed) ---- -- ------ ...: L--------------------------------------------------••-------------------------- --------------------(Owner and/or Contractor) By------------------ ---------------------------- ---------------------------------- ------------------------- } ----------------Title - --------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE------------- _..: REVIEWEDBY--------------------------------------------- -------------------------------------=------------ ----------------------------- DATE------------ ---------------- BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------------------------- Alterationsand/or recommendations--------------- --------------------'--------..........-------------------------------.------------ -•-----------------•-•----• ..--------------------------- -------------------•--••--• --•----------- -----------------•- -------------•---•-------------------•--------------- • --- ............................... i ---------------------------•---.-.-.....-.._.-......_-...--....-...------.......---..-...---------------------.......-_.-........-........_....---'-•-----........--.-....-----------.-..._....-..---------------------------- FINAL INSPECTION BY----------4��-------------------------- 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