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APPLICATION FOR SANITATION PERMIT Permit No. ...4�JI -- ------ (C m late in Duplicate) Date Issued ---.---- 44 Applica�ion is hereby made to the San Joaquin Local H alth District for a permit to construct and install the work herein described. This application-is made:in compliance with County Ordinance No. 549. j JOB ADDRESS AND. LOCATION. % 0W7*---ZXM/ 77 HSTF_G ..__ 9_-LA --1.yr�l.._--�Q.�=H-_s�_ - -------- _ ,.?. lir_ Phone_// :' Owner's Name------- C�-N/f*� .�.Q------ 13 ¢ r Address ax----, 1---77---------•,��C/t��/1/ //�� , G --------------------------------------- __ Phone-/f-l�_`.:f ---l- Contractor's Name--- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel El Other [I} f _� s. 1--__ Lot size .__c�..�C/�C�------------ --------•-------- Number of living units:._/----- Number of bedrooms --_____ Number of bat t Water Supply: Public system'❑ Community system ❑ Private 5& 'Depth to Water Tablep. ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ -Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ s �. Previous Application Mader ❑Yes No %, New Construction: Yes.❑ No; ] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank- ,t4- Distance from nearest well-----------------Distance from foundation-------------------Material------________________________________^__-____.. ❑ 1S No. of compartments----- ----------------------Size--- -- ----1------- -Liquid depth----------------- --------Capacity-------------.:--------- D'+sposal Field:,jC Distance from nearest well_________________Distance from foundation--------------------Distance-to nearest lot line------F:--------- 1 ❑ ,,,*t 51-1 Number of lines--------------==---------- '------Length of each line-----------------------------Width of trench----------------------- ---------- Type of filter material----------------- ------Depth of filter material------------------------Total length----------------------------------------- Seepage Pit: Distance to nearest well - r':- ----Distance If from founda+ion__;&_6r....__..Distance to nearest lot line_.�a---.---- i �.-•-----------.Depth. L Number of pits_C_fNE---------Lining material_ - ----Size: Diameter_ _ fU91 Cesspool: _ Distance from-nearest well-----------------Distance from foundation--------------------Lining material_._______.____-__.____-----__" gals. ❑ ..Size: Diameter----------------------------------- Depth ----------; --Li Liquid Ca aci ------------•-- Distance from nearest building.____________________________________._. Privy- Distance frominearest well---------------------------------- ! ❑ :.-r Distance to nearest 4ot line._ - ----------------------------------------------------------------------------------------- ---------------- Remodeling and/or repairing (describe)---- ----------- ---------------v---------------------•-•------ ---------------- --------- `= -----------------------------------6 ------ f° y7 •------------- - ---------- -------- �•------------ -------------------------------I------•----------------------------------- C,- --- --------- -- I hereby certify that-l-kav pared +his-applica+ion and +hat the work will be done in accordance with San Joaquin County ordinances, State laws„ and ales d regulations of the San Joaquin Local Health District. � n _______,_-y._____.__F .f� � - � F {O e r ctar{ wn and or Cont a' (Signed)------------------ �` 1 {T i+le]- ' - ----- -- --BY:(Plot plan, showing size�o-f'(ot, location of system in relation to wells, buildings, etc., can be plat reverse side]. FOR DEPARTMENT USE ONLY DATE -- APPLICATIONACCEPTED BY------------- ----- `�-, ------ .---------------------•------------•-------------------- •�----------------------------------------- - • DATE------ --------- REVIEWEDBY---------------------------------------------. .-- ---- ---------- : ._ � - - - ` _ . s BUILDING PERMIT ISSUED--------•------------ - DATE - ---- ------------------ Alterations and/or recommenda+ions:__-____---.-_----- -------- ----- ----•-----•- --+ 6 - ---------------------------------------------------------------------------------------------- -•--•------------------- r y -------------------------- •---------------------------- { ------ --------------- ----------------------------------------------- -------- ----------------•------------------------------ -------a-------------- FINAL INSPECTION BY:..-.___ _ Date------."--- ----- --•---- SAN JOAQUIN LOCAL HEALTH DISTRICT 132 Sycamore Street 814 North "C" Street 130 South American Street 300 West Oak Street Trac California Stockton, California Lodi, California Manteca, California y. `/ ES--9-21v1 Revised W-2100 �,