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f � �_7��'- �, �-J 2' ', PPLICATION FOR SANITATION PERMIT Permit No. ----•- � (Complete in Duplicate) Date Issued - ^---=- -°- n� A lication is hereby made to the Sail Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordin nce No. 549. ! - Y - ----------------------------- JOB ADDRESS AND LOCATION________________ Owners Name--------------------------------------- ` ------- Phone_ Ct:_�' Q 1 ------------------------------ = -----------•--•--------`-- ------ Address__ -------- . ----------- J -- -- ------------------- Phone �=�� -------•--- i Contractor's Name---------••----------------------- ---<- - + f Installation will serve: Residence )�q__Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 1 Number of living units: Number of bedrooms -I- Number of baths I--- Lot size --—------------------------- Water ------------------------•- Water Supply: Public system Community system 0 Private ❑ Depth to Water Table ! ft, t Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay F1 Adobe Hardpan Previous Application Made: Yes F11NoA New Construction: Yes ❑ No ❑ /U'r (ju TYPE OF INSTALLATION AND'SPECIFICATIONS: V (No septic tank or cesspool permitted if public sewer is available within 200 feet.) v _ Septic Tank: Distance from nearest well-----------------Distance from foundation__________________.Material_____________-__________-- ❑ No. of compartments------------------ ------Size--------------------------------Liquid depth--------------------------CapacitY----------------------- ` Disposal Field: Distance from nearest well------- ---._.Distance from foundation_-_____-_______---Distance to nearest lot line_________________ Number of dines- Length of each line ------------------Width of trench---------------------- ----------- Type of filter material-------- -- ------ ---Depth of filter material--------------:--------Total length------•----------•-------------�•�-- � a-10-�___-.Distance to nearest lot li`__/ -------- See a`e Pit: Distance to nearest well___ __ _I _ ___Distance ro foundation_ �� k /� 3.3. -----_Depth-----18-------------------- � Number of pits__,_____________-Lining material_________ _-_�____-Size: Diameter___ Cesspool: Distance from nearest well________________Distance from foundation material____-----___-----------•------•els. ❑ Size: Diameter- r--------------------- ------Depth--------------------- -----------------------------Liquid Capacity g Privy: Distance from nearest well-------------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot kine------------------------------------------------ --- ---------------------" - -------------------- --------------------------------------- Remodeling and/or repairing (describe):------------------------------------------------------------------------------------- ------------------- -------------------------------- ---------------- ------------------------------------------------------------1-f--------------------------------------------------------------------------•---•------------------------------------------------------------- -------------- ( I hereby certify that I have-pfepared his application and that the work will be done in accordance with San Joaquin County ordinances, State laws a rules and reg ations of�Sequin Local Health District. Contractor} (Signed)--------- F -- -----��i- ------ ----------------------------------------------------- Title - -- --------------------- By:_ ---- ----------- (Plot plan, sho ng size of lot, locati n of system in relation to wells, buildings, etc., can be laced on reverse side}. FOR DEPARTMENT USE ONLY DATE-- - APPLICATION ACCEPTED BY_____ REVIEWED BY---------------- ------------- ------------------------- - DATE-- ------ -------------------------------------------- BUILDING PERMIT ISSUED------------V-- ------------------------------------------- --- ------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:-------------------- ---------------- ------------------- ----------------- ------------ ----•---- --------------------------- -------------------------•---------- -------------------- ------------- ---------------- ----- - - # FINAL INSPECTION BY.- -- ---_ ------ ----- ?------------------ Date SAN JOAQUIN LOCAL HEALTH DISTRICT 3o0 West Oak Street 132 Sycamore Street 814 North "C" Street 130 South American Streit Trac California Stockton, California Lodi, California Manteca, California y, ES-9-2M a-51 Revised W-2100