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m APPLICATION FOR SANITATION PERMIT Permit No. . �ILCP____-____--- (Complete in Duplicate) Date Issued Applica¢ion 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 LpOCA,TION / ----- �---- "+ �r --------- --------------------------------------------------------------•---- ' Owner's Name------ t`'i _-------/ -- - ------------------------------------------------------------------------------------- Phone------------------------------------ 1-_0_ r Address---------�- -----'---�------- Contractor's Name--------&./4:. ----i.-_u /1---------i-------�6'-----111_10,�. e Installation will serve: Residence ® Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ ' Number of living units: _/___- Number of bedrooms -2__ Number of baths ___/__ Lot size ---1__Q_____-X__h p Water Supply: Public system A Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: ,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [� Hardpan ❑ 1 Previous Application Made: Yes ❑ No ® New Construction: Yes II No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: 'r is�e from nearest well______________Distance from foundation-------------------_Material____________.______________.________.______. El No. of compartments--------------------------Size--------------------------------Liuid depth----------- ------ _ _ Capacity Disposal Field: a istan e from nearest well_________________Distance from foundation--------------------Distance to nearest lot line---------- _r: - --- ----- Len th of e Width of trench. F r r ❑ um r o7 Imes------- 9 ---------s} Type of filter material-------------------------De of filter material------- -_-__---------Total length----------------------------_-------••'" # Seepage Pit: Distance to nearest wel!__.._---_.______ istance from Q-'144 7e - -9.___._..Distance to nearest lot line__t�Q------::_K !+ -------------------- Cesspool: --� -a �] Number of pits____I______________Lining ateria# ��__��r.Il�ize: Di eter_._.5_�-_-__._-_.__.Depth___.__._ ~- Cesspool: Distance from nearest well__-_---_------------------ an an rom found ____________________Lining material_-__--__________________.___________. ❑ Size: Diameter `------ --------- ------.Depth----- ------------ -- ------ ---------------.-------Liquid Capacity----------------------------gals . Privy: Distance from nearest well--------------_----------------------------------Distance from nearest building---__._.______.______________--_____..._�. ,r ❑ Distance to nearest lot line--------- ---------------------------------------------------------------------- ---------------------.---•---------------------------------- w� Remodelingand/or repairing (describe);-----------------------------------------------------------;-------------------------------------•-------------------------------------------••-------- . •-•--•-----------------•------:-----------------------------------------------•----------------------------------------------------------------------------------------------------- ----------------------------------------- ---------------------------------------------------------------------------------------------------•--------------------------------------------••----------•---------------•-------------------------------- --------------- ---------- -------------- --------------------------------------------------------------------------••-• -----••---•• ------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sf laws, and rules and regulations of the San Joaquin Local Health District. (Signed)-•------- --•----- - ---`----��—LYi��--=------------------------------------------------------------------------------(Owner and/or Contractor) / �Cf /� ---- Title r (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICAT ON REVIEWEDI BY__ACCEPTED BY---------=---------- �------------------------------------------------------------ ------ DATE-_ ----��~-� - ------------------- I \1: PERMIT ISSUED--------------••----- ------ �-'- � DAT ----------------- `�� Alterations and/or recommendations:----- ------ �----------------------------------------------------------------------•----•------•--...--•- ---- ------ --------- ----------•-------------------- ----------------------------------------------------------------------------------- -------- ------- ---------- ---------------------------------------------------- -- k ----------- ------------------•----------------------------------------------------_----------------------- FINAL INSPECTION BY:_,-------- ------------- Date--.---- ----- --- ----`5------ --------- -------------------- 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 : Revised W-2100