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rlD� APPLICATION FOR SANITATION PERMIT Permit No. ..l_Q________________ (Complete in Duplicate) bate Issued 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. 549. JOB ADDRESS AND LOCATION----------------- ---f-,3 7`------ -----------L �X, 31-- �, ,�...� . , ^ � .. .. .s. �. .. ..,P..oOwner's Name- -------- -�-- ----------------------------------------- -------------- ------- ------- _ =r �-i• - = - -- ---------------------- S__ =Addres --------- ---- ------------------- ' ---Contractors Name. aaPhone-NA--c-------- Installation r� Installation will serve: Residence Aprtment House ❑ 'Commercial Oj Trailer.Court ❑ Motel ❑ <Other ❑ } ` Number of livin` units: _ _:__ bar of bedrooms __Z�Number of baths ___/.-Lot size f_ - g 'Q /�y Water Supply:- Public system Community system ❑ Private ❑ ;Depth to Water Table = t Character of soil to a depth of 3 feet:= Sand 0 ,navel [:] Sandy Loam E] Clay Loam ❑ Clay ❑ i Adobe Hardpan E-1Previous Application M ❑ade: Yes No /New Construction: Yes E] No ❑,✓TFHA/VA: Yes ❑ ;No G----' t TYPE OF INSTALLATION AND.SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet,) t , �:- �Ois't_nce �w - s � --- n Liquid depth --M-- - ----�Capacity l Septic Tank:- � Distance from nearest well________________Distance from foundation .Material. ------- __7o --__.--. 4 - 't'i ` of.Ycornpartments----- T---- ---------ySize----.----- x k { . I s; z ante from foundation__, Distance to nearest lot line__,__�_.-_... --:------ r Disposal eld'� Numaber of lines----re-----st ------------- Length of each Gine----- -- --_--_--_-_---.Width of trench---- --'t�---- L� Type of filter material___Z''(7:l __::__`Depth of'filter rnaterial----IT---- Total . � - y �_ -.______________________ r r otineSeepage Pit: Distance to nearest wellDistancefromyfoundation____ _____ _Distance to nearet l ----------------- -Depth-* :_____.______.._ Depth-'---.__. ----____-- ❑ Number of pits------ -------------Lining raterial------- '_-----Size: Diameter----------------------- Cess - ---.---__ Cess ool: Distance from .nearest well_________'-<___Distance from foundation________-----------Lininmaterial------------- _____________:__________- ❑' Size: Diameter------------ - i Depth -- -- ----Liquid Capacity - gals. i. Priv Distance-from nearest well ______________Distance from nearest buildin -- -..---_. Distance•to nearest-lot-line:_==___.____ Remodelinuq and/or 'rep firing (describe) = - ' . � t f .�: r £ ` -------------------- + �' l .._.._ •J ` `2 rte • ------------------- ----- - /fes ------- ----------------------------------------- ------- -- ---- -:----` ---- ..� 1 hereby.certify that I have prepared this application andlfhat the'work will-be done in accordance with San-Joaquin County ordinances, State laws; and rules and reguldtibns 'of the San Joaquin,Local Health District. Si ned � c 1 1- - ---------- -- - -,--(Owner and/or.Contractor . . LYS ( g ) � v ( 1 f :� -■- t = . /.sf! j (Title] l � r_:- 1� .---------------- f j�P (Plot plan, showing q of lotJocation of system in relation to wells, butldingi, etc., can be placed on reve#se side ). # ^ _., ';0 EPARTMENT USE ONLY r :. x -----� --------------------------- � ��3_� _-s�.i�- �-----•---- REVIEWED BY--------- ' ---=-------- ----------------•-----•-•---------- -----------••-.._ DATE----...� --------••-•- APPLICATION ACCEPTED BY_-____ ----.f- {-- ; : -------- -------------` DATE----------------------..- ING Alterations and/orTrecomm ndations:---t----•-----------------�-------�._---------------------------------------------- DATE- ----- ------ -------------- =-------------------------- i ------------------ ---------------------------- u, __ __,- —,i -� ________________________ _________ ___________ a ___________________________________________________________________ _ ________________ ---------___________________------_-------------- _ ________ _______________________________ _________________________________.______-r _ ---------._____ _______..___ ____.-___.__ __._.___--__. -------------------------------------- --- ___ -_ ---.._.._______ -____________I - _____ _ ________ ----------------------------------- ----------- - --------- --------------- _.._._____ 1N ( t .. ----------------- ------- �- Date - -1._ --- ` FINAL- SPECTION-�BY:- - - ---- - •----=- -- -'"�--_' -- -- ----- --------------- 4 I SAN JOAQUIN LOCA 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 Revisea 1.57 F.P.CO. �,