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�1�1 APPLICATION FOR SANITATION PERMIT Permit.No. .....fI1/___S___ (Complete in Duplicate) 111 -- - Date Issued --------- Applica*ion is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is made,in compliance with County Ordinance No. 549. x JOB ADDRESS AND LOCA -I N.- _ - �`�----------- --�------�------------------------------------------------------------------- �T fJ ------------------ -------- Owner's Name--------- - ---= �-- --- -�--------------- -- -----------------------------------•------------...-----•----•----=------- ��---__� Pone------------------------- ---------- Address----------�-----•------------ _ -�-------- -_ G�,_ Contractor's Name-----='- ��- �' -- - ------------ --- - ---------------.Phone_ .- "-_.7. -6-7 a Installation will serve: Residence Q Apartment House ❑ Commercial ❑ Trailer Court-❑ Motel ❑ Other ❑ ` Number of living units -12-__ Number of bedrooms _-,•;Number of baths __X_ Lot size --------.1-7-5 _I-__-._--_____-______ Water Supply: Public sysfeirr & Community system ❑ Private ❑ Depth to Water Table __40ft." Character of soil to a depth of 3 feet: .Sand ❑ .Gravel-o-' Sandy Loam E'1' Clay Loam ❑ Clay ❑ Adobe V�, Hardpan ❑ y Previous Application Made: Yes ❑ No E!�_. New Construction: Yes :E] No E TYPE'OFIN5TALLATION AND SPECIFICATIONS:- (No PECIFICATIONS:(No septic tank:or cesspool permifFed.if-public sewer is available within.200 feet.) , Septic Tank: Distance from-nearesf well--- •e_.Distance from [ No. of compartments__ ___Liquid depth-__ _____________ Capacity---.--- -U_ ____ Disposal Field: Distance from nearest well---A/distance from foundation_ __: ___ __.Distance to nearest lot line----Zf-___ M Number. of lines------__/-------_______ Length of each line--------Ar,6__----------Width of trench__-___.,�--�-��______________ Type of filter material',______ _._.__ IDepth of filter mate na1 __,_:___fTotal length---------- _4---------------------____ Seepage Pit: Distance to nearest well'--/_'%/&-xjP..Distance from foundation--- ,/_s�_.Distance nearest lot iine_____�r f � f_-__:_------Lining material_e,__�'--_�%�•S•i� Diameter------- -__ Number of pits_ __ O_ -.Depth------- t�-- [, _' Cesspool: Distance from nearest well__---------------Distance from foundation--------------------Lining material__-__-______________-______-_-___-___ -- sSize:,D.amete r- -----:Dept's---- - -- - `•.-`,_ = LiquidXapaci-- ----=------------ - - Isr-•V7_-.A Privy:# Distance from nearest well----------------------------------------------------Distance. from nearest building__'__-_--__ __________________________-_- ❑ ,. . �:..« Distance to nearest toMine------ --- .. _ ,- - ---------- -------------------------------------------- Remodeling and/or repairing (describe)___________________________ E ------------------------------------------------------------------------•-•-------------------------•-•-•--- --------------------------------------_________________________________________________----:-__--_.----___-___-_____ ---------------------------------------------------------------- __--__________________________________________________________________________________________ + k x I hereby certify fhat 1--have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta}e ws,' and rules and regulations of the San Joaquin Local Health District. h(SignedS -� rte- - t -- -:------------------------------------- -------`--- ----------------(OMcner and/or Contactor) r Y:-i (Plot plan, sowing size o -7:� _ c_ -t -f R rile - f lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- DATE---'-'--DATE �� REVIEWED BY------------ S DATE �..._-. ---------- ------------------ -- ---------------------------------------------------------- DATE PERMITISSUED-------------------------------------------- -=----------•-•---------------------------•--------=--- DATE------------------------------------------------.............. Alterations and/or recommendations:-------------------------------------------------------------------------- ........ ----------------------------------------------•••--.......................... --------•---- ------•----------------------------- -----•---------------- ---•---•--•--___----••-•---------•-•-----------------------•-------•---------------------------------------•--.--I——------------•----------------•----------------------.-------•----------------------------•------------- I FINAL INSPECTION BY:.-, , ` "-=---------- ----------------- ------------ Date- ` - C!.------------------------------------ SAN -----__----------------------__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 ; ' Revised W-2100 5