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11 �� APPLICATION FOR SANITATION PERMITPermit No. (Complete in Duplicate) Date Issued I 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 ADDRESS AND LOCATION-------- �e1 r ----------- ------------------------------------------------------------------------ I 7AddrOwner's Name-----01-�_�------s,.!_e-_ WS�Gn---------------------------------=-•---•--- ------- Phone ` id 7- - Address ess 172- ------ Contractor's Name--------------------. --------- --------------- ------ Phone.- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ k Number of living units: ._ Number of bedrooms _- Number of baths j___ Lot size ZU—' ?� _______________ __ Water Supply: Public system Community system ElPrivate ElDepth to Water Table Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe-9 Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No-2�, FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: I (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-----------•----------- Di sal Distance from nearest well- Distance from foundation__%:tC`-____.Distance to nearest lot Number of lines-------}---------------------------Length of each line------1I'.0-_"_-----------width of trench____r __ _f" Type of filter material_ PT_-Rjt ------Depth of filter material-------l_e_----------Total length___._�/2)---------------------------- Q 4--�g,o o Distance to nearest well_-N c�v---_--Distance from foundation____1tiY-�___.Distance to nearest lot line_____-_ `_ __ Cl 'A Number of pits---.----./----------Lining material__Lwe ll_------Size: Diameter--S--4-..`i------__.Depth_...__/------------------------ Cesspool: Distance from nearest well-----------------Distance from foundation----------.-- ----.Lining material-------------------------------------- E-1 Size: Diameter-------------------------,-------------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well------------------------------------+------------Distance from nearest building__---.-._--_-.---------____-------_--.-. ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------------------------- •� Remodeling and repairing (describe}:______ _ LI, L�x _________________________________ ` ---------------------------------- �-y- -------------------------------------------------- ------------------------------------ f-Lu--�- ----------;----------------------------------------- ------------- ----------------------•- -----------------------------------------------------------------------------------------------------------------------------------r--------------------------- 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, andd, rules and regulations of the San Joaquin Local Health District. (Signed) k'� ..'�J 4 }� ~'� �` � _- Oz., ------------------------- ------------ Contractor) By:------------------------------------------------------------------------------------- - -- --- -------------(Title)----------:--------------------------- (Piot plan, showing size of lot, location of system in relatio wells, buildin , efc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY l k `01----------------------------------------------------------------------- DATE--- ------------------------------ REVIEWEDBY--------------------------------------------- -----------*-------------------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED------------- ---------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations---------=----------------------------------------------------------------------------------------------------•------------------------------------------------- -•--------------------------------------------- - -------------R -- - -------- ----------------------------------------------------------------------------------------------------------------------------------- ---- - ------ - - --------------------------------------------------------------------- I `FINAL INSPEC ON BY:- -- Date------.1-.,� .l-� -------- ------- -------------------------- 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-4-21x1 Revised 1.57 F.P.CO_