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V° tl AE CATION FOR SANITATION PERMIT Permit No. _L -- ___ U (Complete in Duplicate) Date Issued r Application is hereby made to the San Joaquih Local Health District for a permit to construct a / -. This application is made in compliance with County Ordinance No. 549. nd install the work herein described. JOB ADDRESS AND LOCATION---1 76� Owner's Name_-- ------------ - ---•------•----•---•--------------------------•-------- ---- - --- -- ----- --------- • Phone- Address___ -• -- Contractor's Name.-- ----------------------- --- -------------- - -------�� ._--�y_ Phone---,,/ `` ,.}, � - ---------- •-- --- nstallation will serve: Residence 4 r�partment House-E] Commercial ❑ Trailer Court ❑- Motel ❑ Other r os Number of living units: .__INumber of bedrooms -_a-- Numbef bath __.L... Lot size .__ er �' J � � Water Supply: Public systemCommunity system ❑ Private ❑ -Depth to Water Table f,7-ft. Character of soil to a depth of 3 feet: Sand'(D Gravel ❑ Sandy Loam ❑ Clay Loam Q Clay ❑ Adobe[!t—Rardpan ❑ Previous Application Made: Yes ❑ No Lam-- New Construction: Yes ❑ No [�-^� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 2,001 feet.) Septic Tank: Distance from nearesi well No. of compartments------ ________________Distance from foundation__:._.____________J Material................................................. _/ ------------------Size- - ------ --------Liquid depth-------------------------- r Capacity-- \ 1W1 -------- Disposal Field: Distance from nearest well_________________Distance from foundation----_____________._.Distance to nearest lot line----________._.. y,p Number of lines---------------------------- Length of each line-----------•..................Width of french Type of filter material_________________________Depth of filter material----------------- Total length---------- --------------------......... Seepage Pit: Distance to nearest well i !Y_1 ___-Distance o foundation__..1. ---Distance to nearest lot line__ IL)- i Q` Number of pits---- _____Lining matenal_. __._._ - -_Siie: Diameter__ / `c t� Depth_f 14- ----- Cesspool: Distance from nearest well.................Distance from foundation--------------_..._.Lining material__...... _._....__...._.....-__---____ ❑ Size: Diameter------- -------• ------ -.Depth--.------------------------------- -Liquid Capacity ---- -----•---_------9 Privy: istance from nearest well......______r:__ ...Distance from nearest building_ '� ❑ istance to nearest lot line---- ----------•--------------------------- ------------------------------------------•------ ----- Remodeling and/or repairing (describe):-- ` -----�� -- x. - a --- ---------------------------------------------=-----------------------------------------------=------------------------------------------------------------------------------------------------------------- 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 the San Joaquin Local Health District- Signed) --- -- - ----- ----( "Contractor) BY= - --- -•--- - -- - --------(Title)--------- ------------- ------ - ------ --------- ------------------------ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY............... ------ ---------------------------------------------------- DATE y / EVIEWED BY---------------- ka • Z - ------------- DATE_..--------------- ...__ - - --------7----------- .•IlILDING PERMIT ISSUED.............. ------____.______ ------=-------------------------------- DATE.-----•---------------•----• Alterations and/or recommendations________________ ----------------------------------------------------------------_.�._.- ---•---------------•--------------------------------------------•------ ---------•--------•--•------ ----- --•-- -- -------------------•---- ------••-- FINAL INSPECTION 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 10.52 Remised W-2100