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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) / -„TFT.��____ Date Issued �;. _� M► s �sµ'r` f 7 57—deo-- 6 2— Application 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. r� JOB ADDRESSrf1ND � LOCATION--- f---s----- #h------•---•--A•-->V- '------- -_._ ------ Owners Name- r.--------°-+�-----4P�holne_ r fj lClI/ ---------------- Address------------------------ P----- ---- --- Address �..7et.,S 467, s -' ___ _-.,� �------------------•--------------------------------- Contractor's Name ✓�� 1 " .__ r-------------------- ------------ --------------------- Phone_��4)1� , Installation will serve: Residence ❑ Apartment House ❑ .Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: _ _ Number of bedrooms __d_ Number of baths -- Lot size /10-0---X_� _11_____________----.__ Water Supply: Public system Community system ElPrivate ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand:❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A Hardpan ❑ Previous Application Made: Yes ❑ No 04- New Construction: Yes �T 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 w !1__, OJE__Distance from foundation-_'.__........Material_ - ____ '•:;,� No. of compartments--- --------------Size__ S-6f 11 ",_r± squid depth----6.7.._...-_______Capacity_100e Disposal Field: Distance from nearest well__A4. vq _.Distance from foundation---f_<-----...Distance to nearest lot line--Zr------- Number [ Number of lines__,--- --_-----_-Length of each line------ ---------...Width of trench 2 !--____._____.____._.. ji_ Type of filter material4_1WpO�-----Depth of filter material---� _- Total length----- _10-----------------_---__--_-. Seepage Pit: Distance to nearest well -Distance from fp /)--'-..--.-..Distancendation__ to nearest lot�•liine-_Ia-----..- Humber of pits__' ^4 -----Lining material__-..—.--Size: Diameter__..�3...----------Dept h_.. .?_-.-_-_---- ---- Cesspool: Distance from nearest well-----------------Distance from foundation........_..-.-----_Lining material-------------------------------------- ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals Ls.. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---------------------------- _-----..-.-. ❑ Distance to nearest lot line------ ---------------------------------------------------------------- -------------=-----•--------------------------------- Remodeling and/or repairing (describe):_- v -----------•------------------------ -------------------•----......- --------------•--••-------------••- ------------------------------------------------------------- --------------------------------------------•------------------------- -------------------------------------------------•----------------------------------------------------------------------------------- ! hereby certify ?have prepared this application and that the work will be done in accordance with San Joaquin Counordinances, State lawules and regulatio of the San Joaquin Local Health District. (Signed)----------------------- -- - ------------------- -- -- -- ----- Owner and/or Contractor) - B . y:------------------- ti 4 (Title) - �� ' (Plot plan, showing size of lot, location of system in relation to wq)is, buildings, etc., can be plaction reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- .-------------------------------------------------------------------------------------------- DATE._ REVIEWED BY,---------------------------- ------------------- DATE- •-- :• BUILDING PERMIT ISSUED------------------------- ------- ------------------------------------------------------------------- DATE------" ^r Alterations and/or recommendations---------------------- --------------•--- -- ---------------•--------------•-•--------------------- t4 t°J� � FINAL INSPECTION BY:_----------------V. T 1�------- -------------- Date_ ---- ---- - - -----�3----------------------------------------------- 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 t ES-9-2M 10-52 Revised W-2100