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6-1 APPLICATION FOR SANITATION PER IT Pe reit No. --------------------- (Complete ---- .---_-----(Complete in Duplicate) Date Issued --------------------- Apph tion is hereby made to the San Joaquin Local Health District for r a permit to/construct and install the work herein described. This a plication is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION.. b.__ Z F_R_��z Owner's Name------------------------------------ —-a--�-•- �'�2A�._��_�---- - - ------------------------------------- Address-------------------------------------------------- --------------Address----------------•--------------------------------- --rte:-��-------------------- ---------------------------•--------------------------------- Contractor's Name---------------------------- ----_ _-f- ....... Phone 07 Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ � f Number of living units: J__- Number of bedrooms _1 "_ Number of baths I____ Lot size _______ ------- Wafer Supply: Public syste :: Community system ❑ Private X Depth to Water Table � ft. jw Character of soil to a depth of 3 feet San ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe �` Hardpan ❑ Previous Application Made: YesNo New Construction: Yes E] No ❑ wl ,��,,� _,_,� pn..cFr TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) tic Tank:�i Distance from nearest well------- -------Distance from foundation--------------------Material___________________________-________________- + `^1 No. of compartments--------------------- Size--------------------------------Liquid) depth_-------------------------Capacity--------------------- Disposal field: Distance from nearest well__�.�__.Distance from foundation---/--_+_------Distance to nearest lot line--16--_11_.__ Number of lines_...______________r�__ Length of each line--------------�_Q_!____.Width of french____ 1 '-________________ Type of filter material_.__/_�-____ _�S___Depth of filter material___________/r?"__Total length.__-_r -__l7__________________________ 5 age Prt: ► Distance to nearest well----------------------Distance from foundation-------------.------Distance to nearest lot line________________. Number of pits----------------------Lining material----------------------.Size: Diameter-----------------------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..----------......_.----------.____---.-_. ❑ Distance to nearest lot line--------------------------------------------------------------------------------------------------------------------------------------------- 1 Remodeling and/or pairing (describe)------ ---- -- --- � ' ' =�1}'� = ------------ ---.•-�"T�? '� �"`"'�}1 .,u--�. --------�-`------------•�- '------ `- " --`-1'----4---ZD1f-------: -•---�a��-_• !.-----•----- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I hereby certify that I have prepared this app [ic " nand that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules"`and regulations of the San Joaqui� Local Health District. 1 �•1--- --- (Signed)---- - (�on Contractor) ----------------- By:_-------_- :• i ' --------------------------- -----------------------------(Title)----f J------------------ (Plot plan, A ' g size of lot, location of stem in relation to wells, buildings, efc., can be pl, eed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- - ---- ----------------------------------------------------------------- ------ DATE REVIEWEDBY----------------------------- - --- -------------------------------------------------------------------------------- DATE------- --------------------------------------------- BUILDING PERMIT ISSUED--------------------------------------------•-------------------------•------------------------------- DATE------------°fes .e------------------------------------------- Alterations and/or recommendations----------- ------ ------- --- -------- - - --- ---------------------------------------------------------------------------------------------------•----------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- -----------------------------------------I-------------------- - ---------------------------------------------- ------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:___ Date___�b_ - -------- -----------------------------------------------l ------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 630 Soufh American Streo•t 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M 8-51 Revised W-2100