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I - APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Permit No. ------------------ /-- Date Issued .---7M)3 Applica-%n 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 0dna e N . 549 01 JOB ADDRESSA CA ON-- --- -/ Owner's Name-- -------------- - - --- -------------- � -------------------- --------------------- ---- - Phone Address--------------- ' Contractor's Name---- --- --- 11-d-10-- r ----------------------------------------------------- Phone" _�- Installation will serve: Residence ❑ Apartment House ❑ Commercial iter Court ❑ Motel ❑ Other ❑ Number of living units: _j---_ Number of bedrooms__---- Number of baths 01." Lot size ----- - -- -- Water Supply: Public system ULI -Communit system Private Depth to Water Tabl ^q- Y Y ❑ ❑ p e�----- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 11ardpan ❑ Previous Application Made: Yes ❑I No tf—New Construction: Yes ❑ No 4g� TYPE OF INSTALLATION AND SPECIFICATIONS: t , (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 ----------------- isposal Field: Distance from nearest well,�r�Distance from foundation----�-6---!-_.Distance to nearest lot line---T-- ----- Ah 4.1e Number of lines-----------1---.- Length of each line_--.---3.v----------._.Width of trench_.- ----------------------- Type of filter maferial--- __ ---- Depth of filter materia __. l---.___-f__V _ .Total length g ------------------------ Seepage Pit: Distance to nearest well_ w"�.----Distance from/foundation----/_:0__00---Distance to nearest lot line--_j --------Number ---- ------ material Diameter i Cesspool: Distance from nearest well------------ --Distance from foundation-------------------lining material--___--.-______----___----.-______--. Size: Diameter---------------------- ---------Depth---------------------•------------- ---------.-Liquid CapacitY.---------------------------gals. Privy: Distance from nearest we€I____----------------------------- _-------------Distance from nearest building----_-----._-_-----------_-___ ❑ Distance to nearest lot line--- -------- -------- ------------------ -----•------------------------ ---------•-------------------------- --------------------- r Remodelingand/or repairing (describe--------------------------------------- --•----------....--------------------------------- ---- --------•------------------•---•--------------- ----------------•--------------•--------------------•--------- --------------•---------------------•-------------------------------------------- -------------------------------------•------•------------------------------- 1 ------ ----------------------------- ----------------------------------------------------------------------------------------------------------------------•----•---------------------------------------------------------- t4 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rule�anregulations of the San Joaquin Local Health District. , (Signed) ---------------------------------------------------------- ner�nrfd9'�r Contractor) BY: t ---------------------------------------- • --•---(Title)--- G ------------ --- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). ' FOR DEPARTMENT USE ONLY 4 _ ` APPLICATION ACCEPTED BY - -- ------- ------------------------------------------ DATE �l REVIEWEDBY-------------------- ------------------------- ---- ----------- ----- ---------------------------- ------ DATE------------- u BUILDINGPERMIT ISSUED------------•----- ---------- ----- ---------------------------------------------------------------- DATE.------------------- ---.. Alterations and/or recommendations:--------- -------- - ---4 -------------------------•--------------------- -----•---- --------------------------------------•----------------------------------------------------------------------------------------------------------------------------.--------------- .......................... ------------- - ---------------------------------- ----------------------------• ------------------------...-...---------- •-----------•---•--- ----------- t ------------------------------ - ---- ----------------------- ---- ------- ------------------- ------------• --•------------ ----------------------------------------- ---•--------------------•---------- -------- FINAL INSPECTION BY-------------- --- -- ----S-------- --••- -------------- Date-. U r/ 5 I SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Stree4 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 145486 AT W60� i2-5q