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APPLICATION FOR SANITATION PERMIT Permit No. aV_b__Q________ (Complete in Duplicate) / ) Date Issued __'____-'_-s_ 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--o----�-�-�----- �Q��---- ,�y!i°' Owner's Name�p------1 r,_94---------f V--�e••---------+------•--•--------------------------------- ----- -------------------------------- Phone-----------•------------------------ Address...-------e... --- X6 GZo - _ 02 do too Contractor's Name----. r- '-------- �' _.V ' _# --------------------------------------------------------- Phone-- �- ---- Installation will serve: Residence tK Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: I.__ Number of bedrooms .2,__ Number of baths _1___ Lot size ---0- A--R-�` -��-------------- Water Supply: Public system )( Community system ❑ Private ❑ Depth to Water Table _0 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [g Hardpan ❑ Previous Application Made: Yes ❑ No 0 New Construction: Yes ❑ No D5 I TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest we1l,6Z0n4 Distance from foi�ndation------7-----___.Material__ -_--_______________il -------------- No. of compartments________.�----------_size---r�.�- —__4/4P_6#j0tLiquid depth______�# .______Capacity_____RA0 AsW Disposal Field: Distance from nearest well_A1013-9_Distance from foundation-----V---------Distance to nearest lot line_____-_____ Number of lines--------------Z-____,.,--_,-----Length of each line---------s�4------------Width of trench------ -7l- '_--------------..- Type of filter material____ --_''*;__Depth of filter material------/ --------Total length-------. ____________________________ Seepage Pit: Distance to nearest well____ --Distance from foundation-----/Q_1------Distance to nearest lot line_______------- Number of pits-------/------------Lining material---e2l+__Xk-Size: Diameter___-zklf-------------Depth------ 0___________________ Cesspool: Distance from nearest well----------------- from foundation------------------_Lining material____--__________________________-___. ❑ Size: Diameter--------------------------------------Depth--------=--- ---------------------------------------Liquid Capacity---------------------------gals. .. r Privy: Distance from nearest well--------------------------------------------"----Distance from nearest building________._______-___--__-_-----_---_____. ❑ Distance to nearest lot line---------------- ---------------------------------------------- --------•------------------------------------------- -------------------- Remodelingand/or repairing (describe)------------------------------------------------------------------------------------------------------------------------------------ --------------------- i ---------------------------- ---------•---------------- ------------------•------•--------------------------------------------------------------------------------------------------------------------------------------- 1 ----------------- --------------------•------------------------------•--------------------------------------------------•-•---------------------------•--- ---•------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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, and rules and regulations of the San Joaquin Local Health District. k (Signed) �04 ' P� 4"S011:10 ©wnerend or Con-t-r�ac.t..o.r I ----------------------------------------------- -------------------------------------------------- BY:--- -----=- ------------------------------------------------------------------ -------------- ----------- . (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). F]OR DEPARTMENT USE ONLY �. APPLICATION ACCEPTED BY--------(.. 3---Z '-,-..- -------------------- ----------------------------------- DATE------/-------�- �------------------ REVIEWI D BY -- --- ---- --------- DATE - -----------------=--------------------------- BUILDINGPERMIT ISSUED--------------------------------------------------------------- --------------------------------------- DATE------------------------------------------------------------- Alterationsand/or recommendations------- ------------------------------------------------------------------•--------------------------------------------•--------------------------------------- :. -------------------------------•----•- ----------------------•----------------------------- ------------------------------------------------- -------------------------------•--•--------•---------------------------- -----------------------------------------------------------------------------------------------------------------•--------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:---------k1-'-.-V- - ------------------- Date------/------- 1 --------------------------------;-- 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 I~5-9-2M 8.51 Revised W-2100