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APPLICATION FOR SANITATION PERMIT Permit N0.C2__23A (Complete in Duplicate) I � Date Issue 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 No. 544. I bed. JOB ADDRESS AND LOCATION-------- ------- / K ------- i,?i! �_ r_'�' �.^ fir?- =------------------------ __ Owner's Name ) a" --- -- ------------ ' -------------------------- -- --e----------=------------S------Address_ = � Phone �zyr -_ ------ Contractor's Name ri -------------------------------------------- ------ - ---- -------------------------------- - ------------- ----------------- ---- Installation will serve: Residence ------------------------------------- -- Phone_.-5-7d- AR--------- (� Apartment House ❑ Commercial ----- Number of living units: -/---- ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of bedrooms _ _- Number of baths --_� �4 Water Supply: Publics stem ----- Lot size ----------------- <� GQ ; PP Y� Y ❑ Communit system - ---"----`--------- - Y Y ❑ Private M Depth to Water Table - Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ S - -- ft. Sandy Loam Cla Loam Y E] Clay F-1Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No KI New Construction: Yes ® No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4} Septic Tank: Distance from nearest well,, - -_-__Distance from foundation_'�3 © No. of com artments---_-�. _ ------Materj,�l�+�r�!�►--%-- ----- ------ Disposal Size r_ - )C-_• '-------Liquid depth-----------. .. -- r Capacity Disposal Field; Distance from neares well_ a_----_-Distance from foundation-.3--�{__,- ® Number of lines_ --- ---Distance to nearest lot line-_-__6-_-- 77 #---__ ---Length of each line/0- `" 17--Width of trench-------- . Type of filter materiaIZ77Z 17 of filter material--- �.__-_ Seepage Pit: -------Total length-----� --------------- Distance to nearest well-_-----_- --_--_ __Distance from foundation.-.:--------------- ❑ Number of pits------------- Distance to nearest lot line_,--_-_-____---- --._____Lining material---__-_--___ + --------Size: Diameter------------------------Depth---------------------------- Cess ool: • ❑p Distance from nearest Weil--- ------------Distance from foundation--------_----------Lining material---_-_---__------- Size: Diameter------------- -- Depth------------------ -------------------------- - ------- -- - _ --- Liquid Capacity Priv - — -- -z. __ --------gals. Y Distance from nearest well------- ----------------- -------------------------�-' r- -- Distance frorri nearesi'bu Idr'n _�. . Distance to nearest lot line-------- g-----=,---______________ ---------------- -------------------------- ------ 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 Coun ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. ' (Signed)-.� _�( — QA � -------------------------------(Ow $Y:------------------•---•----•--•--------------•-------------------------------- �- - ----- - ner and/or Contractor - Ti _ (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can( p.laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ______ --------- -- REVIEWED BY ------------------------ DATE -------------------- -BUILDING PERMIT ISSUED DATE_ ------- Alterations and/or recommendations-------------- DATE---------- ------------------ ---- -------------------------------------- -------------------- :- ------- ----------------------•------- ----- ----- ------ ------ ----- ----- ------ ----------------------- --------------------------------- ------- -- - ----- -------- ------ ------ - ----------- --- ---------- -- -- - -------- --- .--- FINAL INSPECTION BY ---- -- __ Date- _ / �� w SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California Lodi, California 814 North "C" Street anteca, California Tracy, California E5-9-2M 8-51 Revised W-2100 M t