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APPLICATION FOR SANITATION PERMIT Permit No. .�-- (Complete in Duplicate) � r v a- 1 Date issued 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______ _ h oy G v r F— w ► -1 V F ------------------------ d� ------------------------------- Owner's Name----------------------------------- ---------------------- ---- x� � _ --------------------------------------------------------------- Phone Address - . ------------------ --- -- - ---� ----------- -- - ----------=------------------------------------------------------ ------------------------------------------ Contractor's Name________________________ .7 r - �(-'--- --��t��rl-_---�vT�----� -------------------------- Phone---�---- Installation will serve: Residencej&_Apartmenf House ❑ Commercial ❑ Trailer Court E❑ Motel ❑ Other ❑ Number of living un _J---its: x- F 1 ---- Number of bedrooms _-_____ Number of baths �_�rLot size ___ _____X_____,�s:�Q-------------------- Water Supply: Public system Community system '[] Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe JW Hardpan ❑` Previous Application Made: Yes ❑ No L �- New Construction: Yes eNo ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if p_ufblic sewer is available within 200 feet.) Septic Tank: Distance from nearest well _�T_Um/Distance from foun atipn__ _ F _ No. of compartments QD p ' jS i z �l i P �., 'f Capacity . � e�"��,� �__J� „e Li uid depth Ca as Disposal Field: Distance from nearest well-- Q�Li!-Distance from foundation-_�___S_____ Distance to nearest lot Number it lines-- �[__ /-_Length of each line___. Q F- Width of trench____�y-4f"--------------- Type of filter material_-,;��__Depth of filter material__-_____f��'__-__Total length----,�,r�0_`------------- ____- -- Seepage Pit: 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. p - Privy: Distance from nearest well-----------------------------------_-------------Distance from nearest❑ building �Distance to nearest lot line_____________________ ---------- Remodeling and/or repairing (describe):___--------- ---- ----------------- ------------------------------------------------------------- --- ------- _ Y Y prepared this ap ' ation and that the work will be done in accordance with San Joaquin County I hereby certify that ave ordinances, State laws, nd ru and regulations f the San J quin Local Health District. r (Signed)jwsize _------------------- --- (� Contractor) e -- ---------------------------- ____________-------- ------ -- --------- (Plot plaof lot, location system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------,Z7'-_____. _.-_ �„y; -------------------------- DATE-----= REVIEWED BY------------------ ----------------- ------------------------- DATE--------- _/ -----------•--- ------------- BUILDING PERMIT ISSUED---------------- - ---------------------------------- -- ---------------- Alter ions and/or re�ommendafi, nr:------ ----------- �' *r DATE c .w, - ,, - --- ) ------- ----------------- �J� --- --- ---�- _/1F �' "1t --�- ------ ------ ---------- t ---- FINAL INSPECTION BY:-------- _- —�--- ---------- - ------------------- Date------ 4-/ 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 FS-9-2M B-51 Revised W2100