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Ia APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _____ Applica+'ion 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_.o4Q__.,-w -- � - -- --------------------------------------------Q •- •------`-- ----�¢j---- Owner's Name--- ------�--0_,L.kjA_s-- -------- -- - - ---- --------_--- Phone--7-`s11--- Address---- --Address---- ----------------------- ------------.--------. . - ------------------------ - - --~- Contractor's Name--- ------ ---------------------.-------------------------------------------------------------------._...- -------- Phone----------------------------------- Installation will serve: Residence U�' Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __ 1_ Number of bedrooms .- ___ Number of baths )-$A Lot size ..-_-T_ w �(_. --/J2______ Water Supply: Public system ❑ Community system ❑ Private Depth to Water Table _,i- ft. Character of soil fo a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam 2' Clay Loam ❑ Clay ❑ Adobe❑ Hardpan ❑ Previous Application Made: Yes ❑ No U4-" New Construction: Yes R` No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) + �cc-" Septic nk: Distance from nearest well____ __f.�___Distance from foundation____ __ 'f. ' .- ______ _�____._.MatenaL__ _-_ V No. of compartments---------L-----------Size------- C__-_ -- --_--.-Liquid depth--------'_t'-------------Capacity-___/ ---------- D is Field: Distance from nearest well-_ _0.----_Distance from foundation___-'7-0---------Distance to nearest s:. lot n...._ Number of lines_--o `` � Length of each line-.----------- of trench _ , , 41il _._. . maIter material___ � Total length--------- f____TYpe terial_/f flter De th of fi ` Seepage Pit: Distance to nearest-well---- ______Distance from found9tlon__ _ ___---- lstance to nearest lot line../-F....... ❑ Number of pits----------------------Lining material-------------�r-------Size:; 6ameter-----------------------.Depth--------------------------- --._. Cesspool: Distance fromE nearest we!!__;J" '_-_Distance from foundation__ ______.Lining material__' Size--Diameter---------------------------------------Dept.h---------------------- Liquid.,Capacity_-__ ------------- gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-_ _-____-- __-______-._..._---_____.____. ❑ Distance to nearest lot line--=--------------------------------------------------------------------------------------------------------- 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, and rules and regulations of the San Joaquin Local Health District. (Signed)__ ___(Owner and/or Contractor) B ------------------- •-----------------------------------------------------------------------------------------------------------(Title)---------------------___----------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ft APPLICATION ACCEPTED BY --------------------- DATE----f,P - ` REVIEWEDBY---------------------------- - ----•-------------- DATE--------------------------------- BUILDINGPERMIT ISSUED----------------------------------------------------------------- ------------------------------------ DATE------------...----------------------r- Alterationsand/or recommendations-------------------------- ----------- -------- -----------------------------------•-•----------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------- ------------------------------=---------------- --------------------------------------------------- ` ---------------------- -- --------------------------- --•e-------- --- - -------------- ----------- -------------- ------ ---------- ----- FINAL INSPECTION BY:------f -------- Date-------- / f SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California FS-9-2m ; ' Revised W-2100 ��