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�. APPLICATION FOR SANITATION PERMIT , ' IPt No. _d�__----d Z (Complete in Duplicate) ,pp A" Date Issued gication is herebymads to the San Joaquin Local Health District fora permit to construct and install the work herein described. application is mde in compliance with County Ordinance No. 549. F,--, � 4�7_ JOB ADDRESS AND LOCATION �� , [ ----- •:, Itf7 Owner's Name _.�Z_ I ------- -J- - `�p j ----b-v------0-9-JI&`-l"-4 ll&—_IL Phone- �a�'S��!"2 -------- Address------------------------------------------------ �`' ------- Contractor's ----,Contractor's Name ------------------ -- --'- ��=' �� '�~�k �------�`�� ?�,: '�'`,r7�"------------ Phone ��1��---------.. Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court (] Motel ❑ Other ❑ Number of living units: _1____ Number of bedrooms ___Ir__ Number of baths _1___ Lot size ---�Q---------- _----_______________________ Water Supply: Public system Ji Community system ❑ Private ❑ Depth to Water Table c:z4t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeV Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes }W No ❑ 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____1-_Q------ Material_-- ----________. No. of compartments_______________f--_------Size_ ------------------Liquid � - r Disposal Field: Distance from nearest well__80.'__...Distance from foundation__ _ __......... __..__Distance to nearest lot line,_________. [ Number of lines-__________. l g �� ____ Length of each line__________________�4______.Width of trench_____��____________________ Type of filter material___�Ll-----A_��__Depth of filter material----/_8 ......... otal length________D________________________ Seepage Pit: Distance to nearest well__lOS2-'-------Distant fromfQQunclation__1_0_�_____...Distance to nearest lot line_-...___. N Number of pits___ ________________Lining material-144 ----Size: Diameter____------------Depth--- ':_______________-- Cesspool Distance from nearest well----------------- from foundation___________________Lining material_________________________________._. 0 Size: Diameter------------------------------------ Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-__________________________________ _________Distance from nearest building------------------------------------------ El' Distance to nearest lot line---------------------------------------------------------------------- ------------------------------•---------------------------------------- Remodeling and/or repairing (describe)---------------------------------------------- -------------------•_- --------------------------•---•---- --•---- ........ O� ---------------•----------------•-•-------------•-------------------------------------------------------------------------------------------------------------------------------•-----------•--------------------------------- I h 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 f+he-San Joaquin Local Health District. { `�` " fjm - :-r� ------------- ----- �r Contractor (Signed} / (�Z } BY� ----- ----- �. (Title} 1_.f'?')_1� . ?.I?_-- (Plot plan, sh�iwing size of lot, location of sIttem in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ACCEPTED BY--- DATE" -- ---- ----------- ----------------------------------------------------- : REVIEWED I BY--------------------------------- ON ------------------------------------------------------------------------------ DATE-- 55;".---------'------------------------------------ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE--------� -------------------------------------------- Alterationsand/or recommendations---------------------------------=-----------------------------------------------------------------------------e-------------------- 1 --------------------------------------------------=------------------ ---------- --------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- { -------------------------------------------------------------•-------------- ------------------------------------------ --------------------------'----------------------.--------- --------------------= ------------------------------------------- - ----------------------------- ----------------------------------------------------------------------- p `----�_ -- - - FINAL INSPECTION BY:--------- ------- ---------------------------------- �-�------------ ---------------------- Date-- ------ ------ - SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West OakStreet132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California f ES-9-2M B-51 Revised W-2100 � i