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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) y} Date Issued --- Applica+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. 549. _,A.1. 619 JOB ADDRESS AND LOCATION_ Name- �✓ z/? ----- ----------------------------------- Phone� r--0_ -------- Owner's Address---- ----------------------- y�� ------------•---------------------------------------------•-•--------- Contractor's Name---.4"f"" --- - ----------------------------------- -------------------------------------------- Phone---------_---------------------- Installation will serve: Residence 0 Apartment House F1Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-{---- Number of bedrooms - _ Number of baths J---_ Lot size Water Supply: Public,system ❑ Community system ❑ Private ED Depth to Water'Tabl'e'__'--_".ft- L ' Character of soil to a depth of 3 feet: r Sand E] Gravel ❑ Sandy Loam ❑ Clay Loam ( Clay El Adobe [I `' Hardpan C] Previous Application Made: Yes 0 No ❑ New Construction: Yes,E] No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ¢ {` w (No septic tank or cesspool permitted if public sewer is available within 200 feet.) - e _ -- { Septic Tank: Distance from nearest well----��- -_-----Distance from foundation..- _"------------Mat�ial--------------------------��-,��- :x 4Z-------- F------- -Li uid de th -----+� -----------Ca aci ® No. of compartments r' Size q P. p ty.: Disposal Field: Distance from:nearest well .-.--__Distance from foundation---� ----------Distance to nearest lot line------_-_._ I Leng th of each line- Number es----------------------------------- ------------------------------ Width of`trench... _Y! ------------------- 14- ------------------ 1 / � - ---•---------•------------------------- Typeof filter materias-1 - {---DePth of filter material----- - --____--; og J Seepage Pit. Distance to nearest well--- -0----------Distance from foundation_--dao_'._-_--.Distance"to nearest lot e--✓4__'-__... "Size: Diameter---r--.- r ------ De th--- Number of pits------Z---------_ Lining,material------------------- p \ Cesspool Distance #rom nearest well-__-------------Distance from foundation----"---------.----.Lining material---_----------_-----_--"----- i Size: Diameter------------------=-------------_-----Depth----------=---------------- -..�.:,;------------ Liquid Capacity - �9�Is.. f Privy: Distance from nearest well-------------------- ---------Distance from nearest building--------------------•----------=---------- 1 - i .. — ❑ _ � 'Distance to nearest lot line----------- - - = -------- -- --- - ------ -------------•-------------------------------------------------------------- I 1 + i Remodeling and/or repairing (describe)--------=-TM------------------------------------ -------•------------------=---'---• •--------------------•------------------------- ---------------------------- ---------------- . t --------------------------------- - ---------- ------------------ ------------------------- --- --------------------------------------•------•-------`-----------------------------•-------------------:------------:-------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Count ordinances, State laws; and rules and regulations of the Sane Joaquin Local Health District. rr ------------------ {Owner and/or Contractor\ { g # ' I --"-------------- By=---------------•----- _ (Ttt e} (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 # '' ----------------------- DATE- --ox-0 -------------- APPLICATION ACCEPTED BY-_- f _ - ---------- -- } REVIEWED BY--------------------------------------------- DATE------------------------------------------------------------ BUlLDINGPERMIT ISSUED-------------------------------------------------------------------------------------•-•--------x DATE------------------------------------------------------------ Alterations and/or recommendations-------- --------------- - -------------•----•-----------------•---------------------- --------------- ----------•----------- ---- ------------------------------ ----------------------------------------------------------- fi FINAL INSPECTION BY:--s� Date. --.�' -- SAN JOAQUIN LOCAL HEALTH DISTRICT a - 1 130 South American Street 300 West Oak Street 132 sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2M : Revised W-2100