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i APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) 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------------ -------------------------------------------------- -- ----------------------------------- Owner's Name------- Q�-QRZ a------------�d-/0./7/I-------------- - ------------------------------- Phone - - ---------------------- Address---------- --------` r .s _uPIG Y---------------------- Contractor's Name rf ------ Phone A�'� � --- - ------------------------------------------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _-_,2--Number of bedrooms ---3--- Number of baths __Z`Cot size ___ �_,X___ Q-O_______ ----------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table --9('ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No [Q-'--New Construction: Yes ❑ No D FHA/VA. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Se T nk: Distance from nearest weft_________________Distance from foundation-------------------.Material _______________________.____________._ .- No. of compartments------------- ------------Size----------------------•--------Liquid depth-------------- -----------Capacity----------------------- Distance from nearest well-----------------Distance from foundation--------_-----------Distance to nearest lot line_______-________. Number of lines-----------------------------------Length of each line------------------------------Width of trench Type of filter material-'�-------- ---------Depth of filter material-----------------------Total length------------------------------------------ Seepage Distance to nearest well p Q---------Disfance om f undation--_,�_O_-_______-Distance to nearest lot line _--`1_._____ --__.- Number of pits , ---- _--Lining mate Size: Diameter---��-------_--Depth------��---_--------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-____.___-______-_________________. ❑ Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity-- -- ----------------------gals. 0 Privy: Distance from nearest well ________________________________________________Distance from nearest building Tye ❑ Distance to nearest lot line--------------------- - --------------- --------------- ' d Remodeling and/or repairing (describe}:-- ----- fir--------Lry !_+`-------- --------------------------------------- --------------------------------------------.------------------------------• / ---------------- -------------------------------------------------------------------•--------------------------------------•-------•--------------•------------------------------------------------- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances,fs ate a s, and rules and regulations of the San Joaquin Local Health District. (Signed)----- ---------- --- -A------ --�� , //d'I7/---- ---------------------Owner and/or Contractor) !/ ! ------- Title--------------Z----------------------------------------------- (Plot plan, showing size of fot, location of system in relation to wells, bGildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------- --- ----------- ----------------------------------------------- DATE------------REVIEW - -•-- -- FD BY--------------------------------------------------------- -- ----------------------------------------------------- DATE--------- k t BUILDING PERMIT ISSUED -------- --------------------------------- DATE --------------------- --------------------------------- Alterations and/or recommendations:---------- --------------------------------------------------------- ,�rt� ------ � y - -_ FINAL INSPECTION BY:._, LJ _:--__ 'w �z� ~ Dafe. 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 ES-9-2M Revisea 1.57 F.P.170,