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APPLICATION FOR SANITATION PERMIT Permit No. _ffo__�Lo , (Complete in Duplicate) (p . Date Issued ____�y�� Application is hereby made to the San Joaquin Local Health District for a.permit to construct and instali the work herein de gibed. I This application is made in compliance with County Ordinance No. 549. ! r JOB ADDRESS AND LOCATIONf - -1_� -5 �! Lir, -- ----------- Owner's Name .a-�I------� I L -------------------•-- ------------- -------------------------------------------- i - Phone-- -------------------------------- Address---------- I ------ - ------% - J� - d x----------- - --------------- Contractor's Name---------- .-+g t.S- V-5a"as Installation will serve: Residence*�partmenf House [❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ y Number of living units: j-___ Number of bedrooms,-3--- Number of baths -__f___ Lot size -------1----__Gi"C'1 ."` Water Supply: Public system ❑ Community system ❑ Private [ Depth to Wafer Tablev-20-"ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam Clay Loam ❑, Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ NoNew Construction: Yes ❑ No [ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'-cesspool permitted if public sewer•.is available within 200 feet.) Septic nk: Distance from nearestwell"-fO_'—_.___Distance from foundation----C Material--_-_--?'elic/c C No. of compartments..____.---- -----------Size---_ JW v�Liquid depth--- --------------Capacity..�;&& "---- i Disl Field: Distance from nearest well- ll--__._-_Distance from foundation__f1__*_-----Distance to nearest lot line__-�------- a ` Number of lines---------->/-----------------------Length-of each Line-------2.0-_ __-_-----.Width of trench-------- '_-v- - Type of filter material __--RQ_CA�----Depth of filter maferiaL__le- -----Total length--- V �Q----------------_---- Seepage Pit: Distance 'to nearest well---- ------ -------Distance from foundation--------.: a _.Distance to nearest jot line ❑ Number'of pits------- ------- Lining maferiaL--6N-_---_- ----..Size: Qiametir --------------------Depth--------- - ----------------------- Cesspool: --------- ` Cesspool: Distance from nearest well-----------------Distance from foundation------------------- Lining material--------------------------------------- El -___---_______--------'_-_--_❑ Size: Diameter------------------------ Depth-------------- ------- --------------Liquid Capacity. - --------------------- gals. E Privy: Distance from nearest well-------------------------------------------------------- nearest building ------------ ❑ Distance to nearest lot line--- -=� 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 County ordinances, State laws, and rules and regulations,of,fhe�San Joaquin Local Health District. 7? (Signed)-------- -a --s -�---�- - k�-� - -- -- ------ ----� -------------------(Owner and/o1 r Contractor) Y:---------------------------------------•----------------------------- fzerI -- -------------------------------(Title)---------rX71-_Ntfr_17;F"-�------ (Plot plan, showing size of iot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- -- ----- ----- ---- - ----------------------------------------------------------- DATE------- --------- --------------------- REVIEWED BY----------------------------------- ----------------------------------------------------------------------------------------- DATE----- BUILDINGPERMIT ISSUED--------------------------------------------------------------------------------- ----------------- DATE Alterations and/or recommendations:------------- ------------- ----------------------------------------------------------------------------------- --------------------------------------------------------------------.•---------- --------- ---•---"-----"-------•--•------------------------------------------------------------------------------------------------------------------ ._..---------------•-•-------------------------------- ---- •- r FINAL INSPE BY: 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 Revises 1.57 EP.CO.