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APPLICATION FOR SANITATION PERMIT Permit No. [Complete in Duplicate] r 4-1=.&k o)i¢� y ,y-, Date Issued - »� 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. JOB ADDRESS AND LOCATION.._ _. C .4 sf � o►.a` �,.,�� , �,fr�,��, Owner's Name----------_- n rn�� Z- ------- ----------------------------------------------------- Phone---------'`'--�-�'---�'�---•-- Address ---- ---..._ - -- Contractor's Name--------------------------- Fi•t21_.�il-------�_ - ---------------- ----------------------------•- . Phone-------1-=-•.-�'°---�'-�-7----- Installation will serve: Residence [ ( Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ ----- Number of bedrooms _1 Number of baths --- Lot size _-_-_----__L Water Supply: Public system [j Community system '❑ Private A Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeXf Hardpan ❑ Previous Application Made: Yes ❑ No g New Construction: Yes ❑ No ❑ �,r ,.�- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic fank.or cesspool permitted if//public sewer is available within 200 feet.) 'Septic Tank: Distance from nearest well_16-0--(_-Distance rfrom foundation--_1�'___-Material_-_ No, of compartments_--___4--------- r?_ _ -3-/----------Liquid depth.--r ------------Capacity___1P Q_-_---_ Disposal Field: Distance from nearest well-70-----___.Distance from undation_-._�_J__r____-Distance to nearest lot line-- �___Number of lines-----/----------t___i_f_------ Length of each line-------�-�--- _--.Width of trench------- t�-�-------------- Type of filter material----,iX _ ,-__Depth of finer material--19'_'_.........Total length-----�_Or_-_-_._.__.. r Seepage Pit: Distance to nearest we1l_._/4+ ------Distance fr �� o foundation_-�--_------..Distance to nearest lot line__-�U__.___ icNumber of pits----- -_Linin material_� t_qt Size: Diameter-_3_.3_.f--------Depth---S;;��---------------f �. Cesspool: Distance from nearest well------------------Distance from foundation------- ----------- Lining material----------------- ❑ Size: Diameter- ------Depth----------------------------------------------------Liquid Capacity---------------------------- gals. Privy: Distance from nearest well------------------------------------------------- from nearest building--------------------------..__.---------- -❑F1 Distance to nearest lot line---------- ---------------------------- --------------------------------------------=---- - T Remodeling and/or repairing (describe):-------------------------------------------------------------------------------------- \s 1 -----------••---------•------------••------------••----•------------•----------------------•---•----------------------------------------------------------------------••--•--------- ---------------------------- --------------I--------------------------------------------------------------- -•--------------------------------------------• -----------------------------------------•---•--------•-------------------------•-------•- ----------------------------------------pndrues ----------------•--------------------------------------------------------------------------------------- -�' I hereby certify the prepared this application-and that the work will be done in accordance with San Joaquin County ] ordinances, State laws, and regulations of the San Joaquin Local Health District. (Signed)------------ ------ ---- th.+'Q-------------------64n_,,/ [Fr t ` or Contractor] By -------------------------------------------------------------------------------------(Title)---- . (Plot plan, show' g size of lot, to afion of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------- - Y- ---------------.-------------- "------------------------------- DATE.----------- R1VIEWED BY ----------- ----------------- ------------------------------------------------------------------------------- DATE -1_j�:_ `_` ^ BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE ---------------------------------- Alterations and/or recommendations---------------------------------•--------- --------------I-------------------------------------------------------------------------------- ------------------------- ------------------------------------------------------------------------ ------- �� - r � ---- FINAL INSPECTION BY: � -1--------- Date------ ------- -------------------- Z-- 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 e-51 Rev4ed W-2100