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APPLICATION FOR SANITATION PERMIT Permit. No. _x)l1:2-k41.. (Complete in Duplicated Date J>p2w ^ led qg/s-g - r: Application is hereby made to the San Joaquin. Local Health District for a permit to construct and inst0e-wOrk herein described. This application is made in compliance with County Ordinance No. 549. 1hir JOB ADDRESS AND LOCATION_. -7 q ! Z _ -------------- S Owner's Name ^") _u7 � Q---------------------------------------------------------------'Ph6ne_-0%_��. Address ---------- ------------- - _ � --------------------------------------------- -- -------------------------------------------------- Contractor's Name ------------------------------ BLef►��_'S____--- �[?CJeI - ' Y '"'°� ------ --------1-- Phone____--------------- -------- Installation will serve: Residence Apartment House ❑ Commercial Trailer Court ❑ Motel [❑ Other ❑ Number of living units: _-/-__- Number of bedrooms ___(__ Number of baths ;_I--_ Lot size ____-41_5-_X ---- -- v__________________________ Water Supply: Public system ❑' Community system ❑ Private ❑ Depth to -Water Table ______ ft. + Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam (] Clay Loam E] Clay El Adobe Q�rdpan E]Previous Application Made: Yes ❑ No [New Construction: Yes [�N0 ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: { Septic T nk: Distance from nearest well_�ti4k -Distance from foundatio0 fee4.j (No septic tank or' cesspool permitted if public sewer is available within 20 No. of compartments----- ?" --------------Size---1 s` y ---------Liquid depth ----L/ - --------- ----------------- Capacity_ ---- AM -------- Disposal Field: Distance from nearest wel(71zf__ Distance from foundation --- /D__'_______ --Distance to nearest lot ----- P Number of lines ----- /_____________ Length of each line -------- SID _--------------- Width of trench ... ZY_�!________---_-______ el Type of filter material___ `_______-__Depth of filter material ------- /9- ------ Total length --------- _____________ Seepage Pit: Distance to nearest well ---------------------- Distance from foundation -------------------- Distance to nearest ❑ Number of pits ---------------------- Lining material ----------------------- Size: Diameter---------- -----Depth_.----------------__ Cesspool: Distance from nearest well ----------------- from foundation -------------------- Lining material _____.-----------__.____._'._________. d ❑ Size: Diameter-------------------------� --------- --- Depth ---------------------------------,---- --------------Liquid Capacity ----------------------- --gals. ' r Privy: Distance from nearest ---------------------------------------Disfance from nearest building_ --------------------- ----------- ------------- -'_- ❑ Distance to nearest lot line------------------------------------------------------------ ----- - ----- Remodeling and/or repairing (describe) -------------- "-------- --------------------------------------------------------------------------- -------------------------------------------------------- . ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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, and rules and regulations of the S Joaquin Local Health District. (Signe/ ) d "'� = _� - (Owner and or Contractor RY---------------------------------------------------------------------------------------(Title)---------------`-------------------------- - ----------------- (Piot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r• APPLICATION ACCEPTED BY_____ ,___ �__ ------------ ----- --------•--------------•-•-------------- DATE----- %[ 3Sn'- - --------- REVIEWEDBY '------------------------------------------------ `7 '------------------------------------------------------ DATE------ -------- ---------i--------------------------------- BUILDINGPERMIT ISSUED------------------------------------------------------=---------------------------------------------- DATE ------------------------------------------------------------- Alterationsand/or recommendations: --------------- ----------------------------------------------------------------------------•-•------------------•--------- •------------------------------- -------------------------------- ----------------- ------------------ --------------------------------------------------- -----------------------------__ -----•--•----------------------------------------------Y --- --•--------------------------------- FINAL INSPECTION BY:-- ------- Date - ( -0✓ '! SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street. M _ '.132 Sycamore_ Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California • ES ---9--•2M Revised 1.57 F-P.CO-