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VF t APPLICATION FOR SANITATION PERMIT Permit No. Y 47-10 (Complete in Duplicate) Date Issue ------ 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...v2 30____ ,_. •------- Owner's Name.........�-------- • =._YT..-----<l ---------------------------------------------------------------.. Phon " _ (� Address `.... -- ------ •----------•--. . --•--=------------ -- /,� o - Contractors Name. 1.a , = ----------=----------------------•--------------------•--- Phoni e- 'Q--4.� !.. Installation will serve: Residence 0,"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: :____ Number of bedrooms J. Number of baths -4._. Lot size ------- _•_____________________ Water Supply: Public system Community system ❑ Private 0"Depth to Water Table _Al ft. Character of soil to a depth of 3 feet: Sand Gravel E] Sandy Loam E] Clay Loam ❑ Clay E] Adobe�ardpan ❑ Previous Application Made: Yes E] No New Construction: Y s No K/ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is availab a within,200 fee .) Septic T nk:, Distance from nearest well-----------------Distance from foundation--------------------Material-------_.._.___---------------------------------- El _______-___ _-___-.❑ 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-___-_.__..__..-._______.._........ (J Type of filter material-__-_ _______ _________Depth of filter material-----------------------Total length....................................------------- W ye r Seepag�Pit: Distance to nearest well-.---- fro440 'Size: ation.-•- d Distance to nearest lot Gne ...... O Number of pits_..._ ____________Lining material. C_. . Diameter.__-5 c. . .It__-____Depth_ _� _ ------------- Cesspool: Distance from nearest well__________________Distance from foundation. ._____-__-_:.__.Lining material-_____ -_-______ � ❑ Size: Diameter------------- ------------------------Depth------------------------------------------------ ...Liquid Capacity--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-------o---_______----------__--_-_-_.-_. ❑ Distance to nearest lotfine------------ ------------• - ------------------------------------ ------- •-------------------------------------------------------- Remodeling ----- -- ---------------- Remodeling and/or repairing (describe):---------------------------------------------------•--•----------•••-•--•-••-------•-----•------•-••-••--------••-•---•-------•-----------•. . t --••----------------------------------=---------------------------------------•------•------------------ •---- --- a -------------------------•------_...------------------------------. -- I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I and rules and regulati of the San Joaquin Local Health District. iz (Signed) 6 ....... ----. . .........---------------------------- ------------------. ------. ---------- m and/or Contractor) By: ------------------------------------------------------------------------(Title) (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 APPLICATION ACCEPTED BY---------------------------- ............................................ DATE--------- ' !!7 -•-• -•-------- REVIEWED BY......................................... ----------------------------------------------------------------------------------- DATE-------------------- --- --------•--------•-------------- BUILDINGPERMIT ISSUED..........------------------------------ ........................................................... DATE..................................-•......................... Alterationsand/or recommendations----------------------------------------------- .........................--.............................................................................. ------------------------------------------------------------------------------------------------------------------•-------------------------------------.-------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------- -------------•------------------•-•••-•----•••-•-•-----•-------••--•----------------..... ------•--- -----•------------------------------------...................................................----------------------•--------------------------------------------------------------------------•-----•- -••--------- ------------------------------------------------------------------------------------- -----------------------------------•--------------------------------------------------------------------•-•-•--••---------------------- FINAL INSPECTION BY--------------- ------ , ....................... 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 i-9-2M ; ' Revised W-2100