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APPLICATION FOR SANITATION PERMIT Permit No_ _________________ __ �V Q'"f (Complete in Duplicate) Date Issued Application 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---____-- lot ,r ------ i -- ,.._ �_. , - -- -------------- ---------------------------------------- P ne__ _' - Owner's Name Q A7 : + ddress__ ' � aa Contractor's Name---------------------------------- x � R f Qf7S -7"L"T_C.-------- Phone---- Installation will serve: Residence V Apartment House ❑ Commercial ❑ Trailer Court 0 Motel ❑ Other ❑ Number of living units: ---/--- Number of bedrooms;X---- Number of baths ---1- Lot size --- -_ ____________________ Water Supply: Public system ,® Community system ❑ Private ❑ Depth to Water Table 2-��ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 0 Hardpan ❑ Previous Application Made: Yes ❑ No X New Construction: Yes ❑ No [� TYPE OF INSTALLATION AND SPECIFIQATIONS: f (No septic tank-or cesspool permitted if public sewer is available within 200 feet.) Q ptii T k: Distance from nearest welt4' :--__.Distance from foundation--------------------Material _____ No. of compartments------------- -- ---------Size:------•------------------------Liquid de th ------------------------Capacity------ - - -------- �_'. Disposal Field: Distance from nearest well-��/�-e---Distance,from foundation_____ .___ Distance to nearest lot li -�-�_�� Number of lines-------/ 54.0 --__---_r-yt-r _ __Length of each line---- Q_- ___��-.Width of trench_ {�i ----------------------- Type of filter material__1_�-.-JTJC _Depth of filter material---------/__--__Total length_,1&1_1P_________________________ Seepage Pit: `Distance to nearest well__ JQ_y�-e-------Distant f fo ndation.._- _1r.Distance to nearest lot line_-_ _a Number of its----__1 _------_Linin material __Size: Diameter_____ -------- `- - .. p - Lining ---- - -- .3--3Depth---ja-7-77 I Cesspool: Distance from nearest well ___---1-._'_-Distance from fo_undation--------------------Lining material-_-_____-----_-_-------..____________. Size: Diameter-------------------------------------- p � --------------------------- ---Liquid Capacity----.-----------------------gals. Privy: Distance from nearest well-__--_ Det --------.- Distance from nearest building________________;__----__---_____- ❑ Distance to nearest lot line- f Remodelingand/or repairing (describe):--------------------------------------------------------------------------------------------------------------------------------------------------•----- ------------------------------•.---------------------- ----------------------------- --•-----------------------------------•------------------------------------------------------------------------•------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an les and regulations o he San Joaquin Local Health District. e (Signed)_- -_,___-- __ - -_ "---- � - Contractor) Qhs r BY:-------- li ---- ----------------------------------------------------------- (Plot plan, sho ng size of lot, location o system in relation to wells, buildings, etc., can be placed on reverse side). FA DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------------------- ------ ------------- DATE ------------ -- 1 REVIEWEDBY------------------------------------------------------------------------------------------------------------------------------ DATE. BUILDINGPERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------------------------- --------------------------------- Alterationsand/or recommendations=----------------------------- - - ----------------------------------------------------------------------------------------------------------------------------- ------------------------------------ -----------------------------------------------------------------------------------------------------•------------------------------------------------ --------------------------------- -------------------------------------- -------- f FINAL INSPECTION BY: --------------------------------- Date--------- , r-. ----------------------- .. SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American S+roet 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100