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i Ih APPLICATION FOR SANITATION PERMIT Permit No. __ ..Gt_s 3-- U' (Complefe 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 LOCATION----------5§ff -_k -� -----------------------------------------------------I--------------------------------•-- Owner's Name---------------------X- t-----1'- e - ------... -------------------------------------------- Phone Address D� _Q � i fYuTfr Contractor's Name _1 2"� 1------------------------- -- - --- ------------ - -----=------ ------------ - Phone---•----•------------•- nsfallafion will serve: Residence [)( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size Water Supply: Public system ❑ 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 ❑ Previous Application Made: 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: Distance from nearest well-----------------Distance from foundation-------------------.Material No. of compartments--------- ------Size--------------------------------Liquid depth.-------------- � ,` ------ ---Capacity----------------------- 10, Disposal Field: Distance from nearest well__._-- in Q--.--_-Distance from foundation_--._-_10---------Distance to nearest lot line------S ❑ Number of lines-------------- Length of each line----------.-`Yv_� Width of french---------- ---- ff ----------- Type of filter material--------1-_.1-_--------Depth of filter material-------�_ Total length-------------_WQ__-__----- Seepage Pit; Distance to nearest well---------------------- from foundation--------------------Distance to nearest lot line____.._____---.._ ❑ Number of pits------------------------------Lining material-----------------------Size: Diameter---------------- -----Depth-----------r--------------------- Cesspool: Distance from nearest well-----------------Distance from foundation----_------------ Lining material,--.-_-_.------___._____---- 11 Size: Diameter--- ---------------------------------Depth------------- --- - - - ------Liquid Capacity------------ ---------------gals. Privy: Distance from nearest well ------------------------------------- from nearest building ❑ Distance to nearest lot line____.._.__-___.__.___ Remodeling and/or repairing (describe)------------------- ---------------------------------- ------------------------- -----------------------------------------------------•----------------- ------------------ -------------------------------------------------------- ---------------- lication and that the work will be done in accordance with San Joaquin County - I hereby certify that I have prepared this app ordinances, State laws, and rul s and regul tions of the San Joaquin Local Health District. (Signed---------------X---- /�F '--- .ef ---- 777-- ---- -------(Owner and or Contractor) By:------- -- •-- ----------------------- ---- Title ____ ___ _________ _- g p (Plo+ plan, showin e" a of lot, location of s stem in relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- ----------------------------- :-_ _ DATE__._- REVIEWEDBY---- --------------------------�- -- �- v - - -- ---------------------------•-- DATE------------------------------------------------------------� - 81.JILDING PERMIT ISSUER----------------�------ _ �s Afterations and/or recommendations:_Z��/- .--- j _ y �Z � ( s }a7:�oL�. -- ------- 7 Jf 6 X41' FINAL INSPECTION BY:.......--------ly =eD----- ----------- ate 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