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y APPLICATION FOR SANITATION PERMIT Permit ! (Complete in Duplicate Date issue __ _�P -,.5:-3 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 complience.with County Ordinance No. 549, v JOB ADDRESS AND LOCATIONZ�- ___��kf�.�j/�1��L��.;.d_lT ,.1�� -c"`:/�'f�C_��sF�_�rR--.�/��t!.� -- Owner's Name s/7,J� � --------------------------------------------------- --------------------- Phone-l / "� ' Address -- Installation 1tt�Ci Phone_ -- � Contractor's �---Q- -- `� r Installation will serve: Residence D Apartment House ❑ !Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number,of living units: _/___ Number of bedrooms _ n,Numher of baths __ ___ Lot size ___. r CE�!' _e ________________________ Water Supply: 'Public system ❑ Community system ❑ Priva`+e [�epth to Water Table,�-_ _ ft. Character of soil to a dep,h of 3 feet: Sand ❑ Gravel ❑� Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe D---Hardpan ❑ Previous Application Made: Yes ❑ No Ej"�Lw Construction: YesNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) _ Septic TPA: Distance from nearest wells . _-_4 Distancy from foundation. �' Materia :. - /i?C'-.-----. .No. of com artments_-____-- ;_ ____________Sizes- '� `� '`-- p � 9 - - .i� -� --- ------ Disposal Field: Distance from nearesf well,,- .£>--------Distance from foundation_,R_'� -------Distance to nearest lot line__ l `r #Number of lines___________!'-._____,{`_____-___Length of each line----------- -�_--_:Width of trench-----. �f filter __________ Type of lter mate{ial:_:�J�_4y_(-___.__,Depth of filter material length_________ r , ti_ _____ ____ __________ Seepage Pit: Distance to nearest well_,�� ------------Distance from foundation ,C _ __.Distance to nearest lot line__` ��_..._ Number of its___.-___ ____Linin materia v '•-- do - � P f----•-•:-- g �1'��,�.Srze: Diameter_'-��----------Depth_ ;7-7. Distance from nearest Weil-----------------Distance from foundation------------------- material__.__-__..____..___________.--------- ❑ Size: Diameter--------`--- F------------------------Depth------------------------------------=---------•-----Liquid CapacitY----•-------------------- -gals. Privy: Distance from nearest well.-------------------------------------------------Distance from nearest building---------------------------------.._-_---- ❑ , Distance to nearest lot line__________ _ " --- ------------ -- ---------- -------------------••----- Remodeling and/or repairing (describe):------- ... __r_//--�x'_./1_P � ` I . s -----------_• -----•-----------------•---•----------•-------------------------------------------------------------------•------------------------•------------ ---------------------_-------------•------------------------ A t -------------------------•-------------------------------•• ------------------•-----------•----•------------------------•--•---------------------•----------- --------------------------------------------------------------- r r I hereby certify than! Have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and-rules and egulations of the San Joa_q`uin Local Health District. (Signed *l - � Ga`i' �y�f-- --------------------------------------------------------(Owner and/or Contractor) ------------------------- -- Title ) 7 ,,' ---------------- (Plot plan, so mg'size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). i i l; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY --------- --------------- ----------------------------------------------------------- ---- DATE ------------------------------------------------- REVIEWED By-------------------- - --- ---- - -- ---------------------- ---------------------------------•-------------------- DATE- BUILDING ATE-BUILDING PERMIT ISSUED --•-------i------------------------------------------------•-------------------------------- DATE--------- ------------------------------------------ 1 �z ' Alterations and/or recommendations:--, ----------------------- ----------------------------------•--•----------------------------------------------- --••-------•----------- x f ------------------•--------------------------------------------- } --- ----------- -- ------- ---------------- FINAL INSPECTION BY-------------------=------------------ ------------- -------- Date------ ------ ✓rte ---- ----------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 11 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M JO-52 Revised W-2100