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w APPLICATION FOR SANITATION PERMIT Permit No. _ (Complete in Duplicate) Date Issued ------ -__._5.--W Application is hereby made to the San Joaquin Local Health District for a permit o construct and install the work herein described. This application is made in compliance{with Count Ordinan e No. 549. �� ir r JOB ADDRESS AND LOCATION Cs�' -----.i=� . , Q ° ,1 �5 �f1IW -7�, -1�� ----------.�-6_---W eezv-------- Owner's Name----- ------------------------------------------- Phone-4e'C?,-- j- Address----------------- - /��} ` Contractor's Name !l.�..7t T-z/Ye#--------------------- Phone- 7--•- Installation will serve: Residence [`� Apartment House ❑ Commercial E] Trailer Court ❑ Motel ❑ Other ❑ Number of living units:,QNumber of bedrooms6AU_Number of baths j--- Lot size Water Supply: Public system E] Community system ❑ Private Depth to Water Tabiel�``a ft. Character of soil to a depth of 3 feet: Sand [❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or cesspool permitted if publicsewer is available within 200 feet.) Septic Tank: Distance from nearest well---------------=-Distance from foundation- ---------------Material ------------------------------------------------- ❑ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity---•------------ ------ Disposal Field: Distance from nearest well--7-5------.Distance from foundation__,-'-_------Distance to nearest lot line,/49 f u Lenp th of each line--- ___ -- -___-.Width of trench_-,�- _-f t ----------- Type ubof filter material 4� --De gh of filter material---- _---------Total length-_-- --------------------------- Seepage Pit: Distance fo nearest well------------------ Distance from foundation-------------_-_-__.Distance to nearest lot line----------------- n Number of pits--------------- ------Lining material-----------------------Size: Diameter-----------------------Depth------------------------_-------_ Cesspool: Distance from nearest well-----------------Distance from foundation-----------------------Lining material-------------------------------------- F-1 __--------___--__-_------____------.❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building---_---___-_---_____--______-__---_-_- ❑ Distance to nearest-lotTline-- - - -------------- Remodeling and/or repairing (describe]:------- !------ - ------------ -- ------- ------ ---------------------------•---•-------------------- --------------_--• ------•------------------------------------------------------------------------------------------------------------------------------------------ -------------------------- ------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prep this application and that the k will be done in accordance with San Joaquin County ordinances, !fa a Paws, an rules an rHfi � San J quip L ! Health Dis+r' +. (Signed) } ------ Owne a or C ntr = *- ---- ( F actor) By:-------------- /--------- --�---- -- -------------- ----------------(Title) -(Plo+ plan, showi size of lot, Iota+ion otion +o wells, buildings, a+c., can be plat on reverse side]. FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-_ ' ----------- --------------------------------------------------- DATE_1_-__4-tf"- REVIEWED BY -------------- DATE --------------------- BUILDING PERMIT ISSUED---------------------------------------------------- -------------------------------------------------- DATE Alterafions and/or recommendations--------------------------------------- -------------------------------------------------------------------- --- -- ------------------ ------- ----------- FINAL INSPECTION BY:-.- r 7 f! ------------------------- Date_ .. -a_.- ----------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Ladi, California Manteca, California Tracy, California a E E5-9-2M 8-5f Revised W-2100 �