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o� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 191 Date Issued ____/ Applica{ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein descriibbe^d. This application is made in compliance with County Ordinance No. 549. i JOB ADDRESS AND LOCATION ------ �------------------------Owner's Name ---- Phi • Y Address------- •- -•�-a�---•---- -- -- � .. --- - - --- �-• ---------------------•---------------•-•-•-------- - Contractor's Name ------------•---------------------------------- - Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I_.___ Number of bedrooms " _ Number of baths _I--_ Lot size __ i OF � _ , ,�-�------------------------------- Water Supply: Public system ❑ Community system ❑ Privateg Depth to Water Table-&Vft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adob Hardpan ❑ V Previous Application Made: Yes ❑ Ne New Construction: Yes f� No E]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/f1-___I______M feria No. of compartments_ ._._____-_--._.Size _ _w----.-Liquid depth_ f .-.- ------ D 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 q� filter material-___________-----------Total length_-___._.-_________._ Seepa a Pit: Distance to nearest wel ._ �_. ---Distance f m o ation__ / �`'Q ------Distance to nearest ro _---✓�--.- - Number of pits---/---------- ing material _ ._._ .. __.Size: Diameter...... Depth___. Cesspool: Distance from nearest wel ----------------- from foundation-------------------lining material----------------.-------------------- W ize: Diameter Dep.th - ----------------Liquid Capacity------------------- --------gals. Privy: Distance from nearest well-_________________ --------------- ----------Distance from nearest building-------------._.-________ ❑ Distance to nearest lot line------------------`-------------- ---------------------------•- w �+ Remodeling and/or r airin escribeJ:__ _� --------------- --- --------•----------- ------ --------------------------- -- - --- .-•-•-- - ----- ------ --------------- -------------------------- --64---------------------- ! hereby certif that I have epared this applicatio and that the work will be done in cordance with San Joaquin County ordinances, a laws d r and regulations of th San Joaquin Local Health District. (Signed... --------------- -------------- --------------------- ------------------------------ -- --- ----- wner and/or Contractor) B ----------------_ --------------- 4 -------------- Title ------ ---------`---------------------------- (Plot plan, showing size of Io ocation of system in relation to wells, buildings, etc., can be pl d on erre side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------- ------- ----------- --------------- DATE ------------------------•--------------- REVIEWED BY ------- ------- ------ ---- -- - -- ------ DATE-- �±- ._ _ F BUILDING PERMIT lSSUED. ---------------- DATE------ ------- Alterations and/or recommendations:-..._........... . ----- - - - ---- - I •----------------------- -- -------- ------------ ---------------••------- FINAL INSPECTION BY:-------- ----- r �� r 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 E5--9-2M 145446 ATWOOO 12-54