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APPLICATION FOR SANITATION PERMIT Per4t . (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. F This application is made in compliance with County Ordinan e No. 549. JOB ADDRESS AND LOCATION... --- --,/--1/!.�_ -//-- f Owner's Name----------- ------------f! e_ Fw--------------------------------------------------- -- ------------ Phon Address---------------------- ------ -------------•--------�:--- Contractor's Name a G-0-Z f = � �� ------ Phone/.-` �% Installation will serve: Residence Apartment House ❑ Commercials Trailer Court ❑ Motel � � ❑ Other ❑ Number of living units: =„.,,� Number of bedrooms �..�Number of baths ,,._.w_-_ Lot size . �. - --------------- Water Supply: Public system ❑ Community system ❑” .Private Depth to Wafer Table`__ 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 [] Na 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 ._- ❑ No, of compartments----- -__-_ ------- �---!------------Size-'---- ----------------Liquid cJepth------------------- ",Capacity---. ` �� p Y ~� Dis os I Field: Distance from nearest well-Sr _.-Distance from foundation �p !� fp �1.� _---_.Distance to nearestlot in Number of fines---C /]! Len`th ----- ---,ry --r------ - g •_ of each fine--/ .Width of trench �.. Type of filter material/y, -. U fj A6kD,pfh,of fil#er material----- - -----------Total,°length----- ---Q,� r Seepage Pit: Distance to nearest well----------------------Distance from foundation-..-----._---------.Distance to nearest lot line----------------_�ICZZ' ❑ Number of pits----------------------Lining material: ------.Size: Diameter-.---------------------:Depth----------------------- - Cesspool: Distance from nearest well-----------------Distance from foundation----------------- I Lining material--------------------------- ------ 3 Size: Diameter ----- --- ------ --- ------------------------- .T = Depth ----Li Liquid Ca aci - ._ •� q Capac; .--gals.' Privy: . Distance from nearest well----'_.- , — _ _Q___Z__ � ti� . ----------------Distance from nearest building Distance to nearest lot line-------------_--_.__ -__----_ -�� ------------------- Remodeling and/or repairing (describe):._ +___--_- --------------------------•-- o; a: �?� -------- -- ----- ------------- ---------------------_________________ ° -------- __- -__ ----- ------------------ -_- _- „-_-_____ - - -• _________ __________________________ - , ________ ______________ _____________ _..___---_-___---- � ! hereby certi�fyy hat_I hg• a prepar d t s application and that."the work will be done in accordance with San Joaquin County`r ordinances, - aw and r s and regulations of the San Joaquin Local Health District. (Signed)--------------- ------, KO_ wrier end/ Cantr tort I sY: '------ - - !� -------- -1------'f 4 - (Title) {Piot plan, showing si ot, location of system in relation to Is, buildings, etc., can be place on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------ DATE_----''` REVIEWED BY - .------ - t DATE E k" / - ------------- BUILDING PERMIT ISSUED----------------- ---- - . ------ -------- ATE-_/ - - - ------------------------------ Alterations and/or recommendations:_..4_______________ -- z , W --------- --------------------- ------------------------------------------------------------------- :------ - --- ------------------------------------------------ ------------------------------------------------ --------------------------------------------------- y - Cr - FIN$ 1NSP ION BY------ �j ;• 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 ES-9-2M 8-51 Revised W,2100