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,meq S APPLICATION FOR SANITATION PERMIT Permit No. ry 6 ./� (Complete in Duplicate) .,� t Date Issue a4K 3_ Application is here made to the San Joaquin Local Health `Q -- C4 9 District for a permit to construct and install the orfC h�rein d �ibed` This application is a con 'j. . h Coun ' ' rdinance No. 549. JOB ADDRESS AN Owners ' I �_�__ •-•---------- - -- :..: Phone----------- Address--- Contractor's ddress on ratter's ' Name-- --•---- --•---•-----------------•---------•----• a --------- --------------- ---------------------------------------------------- Phone will serve: Residence [► Apartment Housel❑ Commercial Pho,e________________________ ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __'_--_•.Number of bedrooms"___- r - / Number baths __f__. Lot size __ _ XI ' Water Supply: Public system `-------- -a�------------------- ppy' Y ❑ Community system [ ] Private Depth-to'Water Table -------- ft. Character of soil to a depth of 3 feet: Sand Gravel❑ Sandy Loam ❑ Clay LoamCla Previous Application Made: Yes (] No New Construction: ❑ Y El Adobe ' Hardpan E]Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted,if.publi�c seer is available within 200 feet, Septic ank: Distance from nearest well_ _-_____ �'"'" Istencq from a}efial ,r1_ No. of compartments__,___._ 50 __ S-ze__ - ------- �ii r X Liquid depth_. ' L' '. --------Capacity----- __A ` Disposal Field: Distance from nearest IQ_--_---_-.- ° - � ;stance from foundation _!�_ �• Number of dines____-_-___ }•� Distance to nearest Igt I,iPe�r_ _,--_. *� - Length of each line-------- --1�!(f_ il._.Wid#h of trench.------,��f' t Type of filter mater _ �- 11 q ,E i- -- -- epth of filter -.Width y- length_____._.-!�__ �______•- Seepage Pit; � � umber f its.. } well__-__. ____-____Distance fro'm found ti�----------_____�.N Distance to nearest lot line-------..__-___- i ❑ Number of pits----------------------Lining m terial----_.-- _-- : ---------..Size: Diamotero-._._ ----- - Depth-------------------- Cesspool; Distance from nearest well . ` F"' � � ..Distance from'foundation_______________I__ Li'ning.,materiaL____._____-_____._ ❑ Size: Diameter ----------Depth----- -- ----------------- -i Li.uid Capacity Privy: Distance from nearest well_--__--- p y' gals. ------------------------:_t_-Distar ce from ne est building ❑ Distance to nearest lot I;ne 6 y • -- ...... ............................... -------------- ------------------------ Remodeling and/or repairing (describeJ------------------------- T--------------------------------------- e):---- --------------------- ---------- ------------------------7-• - -------------- ---------------------------------------------------------- -- -=-----------•----•---------------------------------------•---------•------------•---•---------- ---------------------•----•--- ------------------------ I hereb certify that I save prepared this application and that the work will be done in accordance with San Joaquin County ordinances, to dws, an rule Band regulations of the San Joaquin Local Health District. a (Signed)- - gy- --------- ------r-•----# es -- -------- (Owner and/or Contractor)--- ---- -- --- --- - ------------- (r}le {Plot plan, showing size of to}, location o system in relation to wells, buildings, etc., cange placed on reverse side). , < • - FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__ -___ - --------------------------•--•----------- REVIEWED BY. -- ...................DATE_. ---------------------------------------- DATE----=�" .-. BUILDING PERMIT ISSUEQ_---------•-------------------- ��--------------�-----•---------`----------- ----- ------•-------------------•---- ----- - ------ DATE!--------LO--- --- Alterations and/or recommendations:______- I ------•----•---.- ---------- r ----•----t- �U ��R,-1 f ---• -l" r ' 1-� -- -rte �,� f_._ _7 ----------------- dye - ----------- -------•---------------------- ----------------------------------- - I------------•--------------_--------------.1------------- FINAL INSPECTION BY:--------- __ _ - '-•-----� ---- ---------- - Date-- --------------- SAN ----------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 10-52 Revised W-2100