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APPLICATION FOR SANITATION PERMIT Permit No. .7�3/- �(Complete in Duplicate) 7 G Date Issued --------------- ----• Applica{ion 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.No. 549. 5 R JOB ADDRESS AND LOCATIONJ �--�---=----tT-c�- -Q- ��.i fJ-�-- Owner's Name------ `------C-AldN---------------------------------------------- -----------------------------------------_ Phone.------------------------ ---------- l � �dSAddress----- --- -TU- ------• _e� _!: ------------------------------------•-----•-------------------------=----------------------------=-----------------.� -_------------------ Phone: �L Contractor'& Name------'--� --r-�--�-1`'=--I�-----`L'---��-'------------------------------- ------ --• -------------------- -----. ------------- Installation will serve: lResidence 2--_Apartment House ❑ Commercial E] Trailer Court E] Motel ❑ Other ElNumber,of living units: _1--- Number of bedrooms -_A__ Number of baths ___ _ Lot size ____ ___________________________ Water'Supply: Public#system ❑- Community system ❑ Private ❑ Depth to Water Table _""_:_ ft: Character of soil to a depth of 3 feet: Sand Ej Gravel ❑ Sandy Loam ❑. Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes E] /-No 0New Construction Yes El No [jj-" ; 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----------- ---------Material-------------------------------------------------- ❑JC(1J !�f No. °f ; from est well _ _____________+R1 stance from foundationquid depth-_-�Istance to nearest lot kine----------------- J, __._._____.__ Disposal Field Distance r ° ❑ f;�i'f' i ny Number.of,lines------- = =Lengih,of each line - Width of trench Type of filter material=:____________ -___-�Depth of"filter material-----------------'-----Total length_ _____._-_-__________________________ p 9 / See a e Pit: Diumaber T. to nee re_st:well_AV�_�ilE=_-_Distance from foundation--.__'f3____;_-•-.is jape to nearest lot line __________ , ❑� of pits---- _---/---------Lining material__{?,C1C-�--.-Size: Diameter-----___•--------------Depth__-v�.3�-------------------- Cess ool: Distance frbm nearest well________________r:Distance from foundation____________ :___..Lining material-_.-_--.___.--_____-____-.____.______- P . ❑ Size:Diameter-----=--=-----"-----=------ Depth----'-------------=----------=---------------- .-Liquid Capacity gals. Priv Distance from-nearest;well__,__._________________________________________Distance from nearest'building--- -_._-_.__.____________-____________-_. \ ...__»Distance�tb nearest lot"line `•-------------�--�------------:----- --------�-�„-- Y i . Remodeling and/or_ repairing (descr.ibe)--------/ --------------------•--------•---------------------------------• ---••---------•---------------------..._....------------.----•----•----•----•--------------. - ------.. ......---. ----------- -- r ----------------------------------•---=----•-----------------------•---------...---------------------------.---------------------------•---------------=----------------------------..-•--------------------- I f 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) l� S�� C. ` ner and/or Contractor ti BY:---------- -- ) -----=--•----------------------------------{Title) --------------------------------------- (Plot plan, showing size of.lot, location of system in relation to wells, buildings, etc., cari be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- ------ ------ --------------- -- ---------------------------------------- DATE------- - - ---------- ---------------- - - . i -- --------------------------- DATE.... ' 1_.... REVIEWED BY ---------- ------ -- BUILDING PERMIT ISSUED----------------------- - ------------------------------------------- --------- DATE-__-_.-------- --- . Alterations and/or recommendats^--- ----=-------- - ------------ ----------------------•-•------------------- ----•-------------------- -- - ------ -----•---------------------------•-------•-------•---•-•---------•------------- ---------------------- q t ---------- ------------------------ ----------------- ----- ' - 1 ------------------------------------------ 1 - , FINAL INSPECTION-BY:-=-------"------- =-=- =----------- Date_----=---4__ -_/_. , -' ----- 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 E ES-9-2M Revised W-2100