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APPLICATION FOR SANITATION PERMIT Permit No. . (Complete in Duplicate) y/ —.17 Date Issued i s 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, JOB ADDRESS AND LOCATION............ n r - ------------••----- Owner's Name_ -- -Q.S..-� .------•----- ---- - ----------------- ------------------- Phone------------------------------------ }. Address --------J ��Z� . .........��U...... . Contractor's Name------ --- ----•----- -q_�IG -----------•----------------------------------- Phone----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ T Number of living units: _ _____ Number of bedrooms ___t"-Umber of baths __e�___ Lot sizeK...____9'0_________________________ j Water Supply: Public syste'mIE—Community system ❑ Private ❑ Depth to Water Table_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy.Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made:. Yes El Nom New Construction: Yes 0—No ❑ z TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest weli__,_______________Distance from foundation.__- _.__________-Material______________.._._____.__._..____________-___-. ❑ (�No. of compartments--------------------------Size------ ---------------------------Liquid depth--------------------------Capacity------ --------------- Disposal Field: Distance from nearest well.................Distance from foundation--------------------Distance to nearest lot line___--___-________ ❑ Number.of lines--------------________ ------- ----Length of;each line------------,.----------------Width of trench----------------------------------- Type ---- - ------------------•-•--- Type of>filter material--------------------_____Depth of filter material----------------------- length____________-------...______________--____ Seepage Pit: Distance to nearest well-t-;��y��Bistance from foundation-----1l---__._..Distance.tQ nearest lot line_x_x�__ Numberlof pits...... -------------Lining material__AC'X /A4I4Diameter__..__-_ -�_ _.Depth_�_�___________________ Cesspool: Distance from nearest well_________________Distance from foundation.------------- -_.Lining material-------------------.__----____.______- ❑ Size: Diameter--------------------------------------.Depth---------------------------------- ---------- ------Liquid Capacity----------------------------gals. Priv Distance from nearest well._..___________-- y: --.._------------ - --Distance from nearest building---------------------------------------- ❑ Distance to nearest lot line-------- --------- ---------••-----------------------------------------•--- --------------------- Remodeling and/or repairing (describe): -------------------------•-----------•-------------------•----------------------------• ----------- v --------------------------------------•---------------------------------------------••-------------------•---•--------------------------------------------•-• -------------------••--------.--------------------------------- -••--------------------------------------------------••--------------------------------------------------------••---------------------------------------------------------------------------------- ----------------------------------------------•------------------------------•----------------•-----------------•--------•--------•------------------------- - � I hereby certify that I have prepared this application and that'the work will be done in accordance with San Joaquin County ordinances, Sta laws, and*;rules and regulations of the San Joaquin Local Health District. (Signed ----------- - --- ----------- ------ {Owner and/or Contractor) By: -- ------------- -----------------------(Title)----- --------- ----------------------- ,; (Plot plan, showing size of Wt, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED:BY---------------------------- -- ------------------------------------------------------------- DATE------------- --------------- ----------------------------- REVIEWED BY---------------------------------- - ----------- ------------- --------- _ BUILDING PERMIT ISSUED:----------------------------------- --------------------------------------------------- ••---• DATE----------------------- ___ Alterations and/or recommendations:------------------ � --- ---- - - ------ } - - - - - - - - - - -- - - -__ . . = -----•----------------- -------•-------�:--: •------------•---- --:--------------------------:-------------------:--------------------------------:---- :::----------------------------------- } ------------------ ---------------- ------ ---- FINAL INSPECTION BY:=_ea.L -------------------------------------- Date-----a-.-----77 —rl5- .------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT t 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C' Street Stockton, California Lodi, California Manteca, California Tracy, California Ee-4 145446 nrwoo❑ _