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APPLICATION FOR SANITATION PERMIT Permit No. ___�zz. - 1 (Complete in Duplicate) crate Issued -1---11••7��• Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This ap lication is made;in compliance with County,O.rdinance No. 549. cot QZ?D= 5_cid' ;�-G�►i�.t T-`.�Gr—ail Er a Lo+ 3 - 2r OB ADDRESS ANQ LOCATION - - ---- --------------------- ► IKk1�hy _. I/[ . �L.fa2rG ►i 1 , Owner's Name ,V -1 c�'C/. -----••--------------------------------=--------------- Phone 3. 1✓J1}� Address "' `------_------J----------------•---- =- - Contractor's Name----- #---------•------------------- S ------•------------------------•------------------•---•----•-------------------- Phone---------------•--•---------------- Installation will serve: .Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living.units: -------- Number of bedrooms __ __. Number of baths J_____ Lot size ----------1(0--,—'------! U4 Water Supply: Public{ystem'❑ Community system ❑ Private I4 Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Et' Hardpan ❑ " Previous Application.Made: Yes ❑ No FV New Construction: Yes No ❑ { TYPE OF INSTALLATION AND SPECIFICATIONS: � ..(No septic tank or cesspool permitted ifpublic sewer is avYilable within 200 feet.) -. Septic Tanki'I'''"^- Distance"-fram;nearestTw�gll___ a _'.- Distance from foundation____t_d----:_.---.Materia€..___==_f!0!'? _:____ _______________________ '";= No. of compartments--------------�--------Size-�� ---RX_,�---:_-.Liquid depth---------yy.-�-----`Capacity-----k5p------ Disposal Field: Distance from nearest we4____�~d _.._.Distance from foundation------��_.__.Distance,to nearest' lot line----- Y Y Number of lines--------- f ---i----.------Length of each line----------- _____._.Width f trenc h1__- _aqrf----- ._. ----------------- ___________ ......TYp orfilter material L__ Depth,of foe � og - fro: undati n_�_ to nearest lot line_____._______-.._Seep ge Pit: DF e to Hearst welf----------------------Distance ❑ Num"Ir of pits---I-----------------Lining material----------- �---Size: iameter------_------------- -Depth------------------------------- Cesspw[I �-i�.•_ . I . , ! r�th' m �'�,z ool: Distance-from nearest l ___________ __ foundation__---_______.____,__.Lining material- _ ___________________--________.______ Siz :.Daes , - -- _, + . { Privy: Distance from nearest ---------------------------------------------Distance from nearest building ner A ❑ - Qisfance•to nearesfo line >` Remodeling and/or repairing (describe)---------- -----------------------------------------•-----•-----------------•-•--------------- -------------••---------------------------•---------- ft s i I ---- ---------------------------------------------•-------------------------•----------------------------------------------------- ----------------------------••------ :.,- -------------------------------------------- I ------------------ ------I hereby cer+ify fhiC have prepared Ais-application and that the work will be done in accordance with San Joaquin County ! ordinances, State law's, and rules and regulations of +he San Joaquin Local Health District. I • (Signed)ned ---------------------------------------- •-----------.(Owner and/or Contractor) g • ----- � (Title)- (Plot plan. showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). x FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - - - DATE--- ----` REVIEWED BY -1f�r~ua '��d� aria-=----------------- ----- DATE----- - -- •-- BUILDING PERMIT ISSU --------------------------------------------__-----------___---------------------------- DATE-----`---------------------------------------------•-------- Alterations and/or recommendations----------- ------ --------------------------- ---------------------------------------------------------------..--. --------•-•-------- ---- ---------------------------------- --------- ----------------- -------------•-•-----------------------•-----••-•----•----------------- -----------------------•--------------- -------------------•------------------------------•--•----------------------- #--------------- --••----I—,------------------------------ ------------------ ---------------------•---------------------------------------- ----------------------- r ` f _ FINAL INSPECTION BY:..: ----------- - ----..-- Date------ �----//- / ?�---------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Stroet 300 West Oak Street 132 Sycamore Street 914 North "C" Street ' Stockton, California Lodi, California Manteca, California Tracy, California r ES-9-2M Revised W-2100 f