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�+ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) ` Date Issued fes__'__�-?.,P.- r Applical-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. 54.9. JOB ADDRESS AND LOCATION____ 2-2-3-0-------- + Owner's Name ,. -U"' -r--------- -w�S. 6t---••---------------•--•------------•------- -------------------------------------------- Phone-------------____............. Address.---.--------------- Contractor's Name------ U" ----------- --------- ---------- ----- :--- ----------------- Phone-0...... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1i Number of living units: ___ ___ Number of bedrooms ---I, Number of baths __�I._a.Lot size ------,1.10----k__11Q_.--_--.____________._-__ Water Supply: Public: system ❑ Community-system ❑ Private A �epth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand F] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: ILA (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 com artments--------------------------Size-------_-------.----------------Liquid de th-------------------------_Capacity v p q p. p tY----- - -------------- Disposal Field: Distance from nearest well----4 A_A.._Distance from foundation____IT---.-_-.Distance to nearest lot line_-�_�____-- �, Number of lines___________ ____ ___A-- -- ---Length of each line--------- .............- Width of trench _Z4�_ ______-_-_---_------ Type of filter material---�_�.__j�_ __Depth of filter material____._I_e_ _______Total length___. -_Q _________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation____.___________.-..Distance to nearest lot line----------------- F1 Number of pits----------------------Lining material-----------------------Size: Diameter----------------------_Depth--------------------------------- Cesspool: -------_------------------- --.Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining material__.___.._.____.__.______--_________ ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity_--------------------------gals. Privy: Distance from nearest well __._________--------------------------------__Distance from nearest building---------------------._________________._. ❑ Distance to nearest lot line------------------------------r-------------------------------------•---•-----------------------------------------------•------------------- Remodeling and/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, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed)------- -�-16----'---- .-. - �* "......1"°~---•-------------------------------{ Afar Contractor) By: �f r(«7C ^+'° (Title)- (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 APPLICATION ACCEPTED BY------- -------------- ----------------------toIU- ---------------------------------------• DATE -� REVIEWEDBY------ ---------------------------------------------------------- .------------------------------------------ DATE- -f ,BUILDING PERMIT ISSUED--------- -----------------------------------------•--------------------------------------------.-..-_ DATE. Alterationsand/or recommendations:------------------------------------------------------------------------------------------------------------------------ ----------------------------------- --•------------------------------------------------------------------------------------------------ -----------------------------------------------••------------------------------------------------•------------------------ ------------------------------------------------------------------------------------- ----------------------------------------------------------------------••--------------------•-•-------=--------------------------•------ -----.----•--------------------------------------------•-------•----------------------------------------------•---------- ------------------------------------------..-------- -------•--------------------------------------- - - -- - ------------------ - FINAL INSPECTION„BY:.......fP ------ Date------ -��--� ---_l._.._------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street - 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M Revised W-2100