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r APPLICATION FOR SANITATION PERMIT Permit No. _7.11__4 v (Complete in Duplicate) X-Y/ Date Issued _ 7- f Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. p I This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION----------- 5,-12 _-,_ _ Owner's Name---------......• -------- L.�_". - rj--P - --------------------------------------------------------- Phone------------------------------------ Address---------------------------------------------------- ----------------------- -------------------------------•-----------------------------------------------•-----•-•---------------•------------------------ Contractor's Name-------I� y -��-- --=9745r- Installation - -~ �=__=------------------------------------------------------------------- Phone---•-;;� �--��--- ! 1 Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [❑ Motel ❑ Other ❑ Number of living units: Number of bedrooms _- _ Number of baths fit Lot size ___,I_v_Q---x_____ _s_____________________ 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 ❑ Clay ❑ Adobe)V Hardpan ❑ Previous Application Made: Yes ❑ No)� New Construction: Yes ❑ No ❑ 11N, r TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation--------------------Material__-------_--______-___________._________------- 4� 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 french----------------------------------- Type of filter material_________________________Depth of filter material-----------------------Total length------------------------------------------ Seee Pit: Distance to nearest well ell--.--__-��-______Distance from foundation_______TA-Distance fto nearest lot line____+k:r_--__--. Seep Number of pits______________________Lining material--- -Size: Diameter______ r__ ___.Depth..... .. -`_______________� Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material______-____________________-.-- F i ❑ Size: Diameter--------------------------------------Depth---•-----------------------------------------------Liquid Capacity--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------__________________- ❑ Distance to nearest lot line-----------------------------------------------------------------------------------------------------•----------------------------•----------- 1 Remodeling and/or repairing (describe)_______________A ----------- -.- ----:_.__ ' ------------------ -------------------------------•-------------•--------•-•-•----•----------------•---•---------------•-•-••------------------•-•--------------------------------------------------------------------------------------------- ----------------------------—---------------------- ---------------------------------------------------------------•-------------------------------------_-•-------------------•-------•---------------------------------------------------------------------------------------------------------------•-------- I hereby certify +ha+ 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 San Joaquin Local Health District. (Signed) ------------------- --- -------------------- v �lz�{Ow�ne�r,and/or Contractor)ont ractor)•. .-_--•• ------------------- - -BY'� -.'------------------------------------------------------------(Ti+le)--- (Plot plan, showing size o lot, location system in relation to wells, buildings, etc., can be placed on reverse side). ) FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- - ------ - - DATE------ ____ REVIEWED BY - --------------------------------------------------- DATE--- BUILDING PERMIT 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,- F-S-9-2M 8-51 Revised W-2100