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i �1 �lv APPLICATION FOR SANITATION PERMIT Permit No. .___....._.�. _.... (Complete in Duplicate Date Issued /71_ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. j This application is made in compliance with County Ordinance No. 549. �-27 .)— JOB ADDRESS AND LOCATION. -------- ------ ---------------------- Owner's G _ �m�, �� � -: Owner's Name_s_JF� Phone ;®.- Address------------/ - -,4-G -- ----------------------------------------------------------------------- --------------- --- -------- -----• f = Contractor's Name---- .. qC-- Phone -is �� 7 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units:/ Number of bedrooms.,:. Number of baths -_ Lot size ___ZQ:'Tl.--__ `o__________________ Water Supply: Public system ElCommunity system B Private E] Depth to Water Table-2.0_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [❑ Adobe PF, Hardpan El Previous Application Made: Yes ❑ No %-. New Construction: Yes 9. No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200-feet.) - f Septic Tank: Distance from nearest Distance from foundation.....r�--�.__ _.Material____ _- rt----- -.-__-_. �. No, of comp artments_.___.s�_________----Size---<J_�.rr__.X-.&Z-_Liquid depth-------c$7E;------_._Ca'pacity-----/-- , Disposal Field: t-,,Distance from nearest well- - ___ .�DEstance from foundation:____ _Ca..r__.:Distance to nearest lot line----- Number of lines------------ � lQ_____. .y_-f'�,'-------Length of each line---- _X.� _.�/ c1th of french-------� _--�-------- Type of fitter.materiai---f�._______4/_�epth of filter material-__.___/_...._.Total length___ _/...gyp____________________ Seepage Pif:. 'Distance to nearest well-----------------------Distance from foundation—..__-_.-_____-...Distance to nearest lot line----------------- )? ❑ Number of pits----------------------Lining material--------_---- -------.Size: Diameter-----------------------Depth---------------------•-•--------- Cesspool:El $izeaDiameter--------------------------------------Depth nearest well---- ce from foundation-----.--------_----Liqund Capacity----------------------------gals. � } Privy: Distance from nearest well---._____.---------------------------------------Distance from nearest building--------------------------------------------r - ❑ Distance to nearest lot line---------------------------------------------- --•------------------------------------------ Remodeling and/or repairing {describe)------------------- ------------------------------------_---.._-_.---------------------••------------------ -----------------------------------•--------------•-- 3. ______________________________________ _______________________________________________....__-________._____________---______-____._______________-___ ____ _ _ ..--------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St s, and rules and regulations of the San Joaquin Local Health District. [Signed)...... [Ow r and/or Contractor] By:._.. -----•. :�� ----------------------------- (Signed) ---------------- ------ [T el ------------------------------------ i#I (Plot plan, showing size of lot, location of system in relation to wells, buildings,-etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- ---- ---- ........... ------ DATE------ ------------- ._ iY - REVIEWED BY_ - DATE------------- f �------------------------------------- ------------------ ....:..... BUILDING PERMIT ISSUED----- ------------� ---------- ------ - # DATE----------------- Alterations and/or recommendations------------------- -------------- - ............._------------------------------------------------- ---------------------------------------------------------- -------------------- ----------------------- f --------------•------------------ -- ---------------------•---•-------------------------------- ----------------------•--------------------- -----------;-------------------------------------------------------------------- ------•----------------•-------------------------- ------------------•------------------------------------- •---------------------------------------------------- ------------------------------------------------- r FINAL INSPECTION BY:----------(2, ------------------------------ Date------------- ;---------------------------------------------- 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 E5-9 145446 ATWU1 0 T.