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APPLICATION FOR SANITATION PERMIT (Complete in Duplicate) Date Issued -- -------fi=r I • �� z1 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---- 1� " � '`7"".ts - - ---------------------•-----------------•---------------- Owners Name---------------- -------- " ---• -------•--- ----------------------------------------- ------------- -------- Phone------------------------------------- ------------------------------------------ --. : - ------------------------------------ Address ------------------ G--?-- � ti Contractor's Name `�`*--------------- - ----- - ----------- -------------------• Phone__. Commercial Trailer Court E] Motel ❑ Other E]Installation will serve: Residence '0 Apartment House F1 ❑ Number of living units: J--- Number of bedrooms _l_--- Number of baths ,f ----- Lot size --- Water Supply: Public system El Community system El PrivateDepth to Water Tabl _A._ ft. Character of soil to a depth ofJ feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes E] NoA New Construction: Yes.jKNo E] I TYPE OF INSTALLATION AND SPECIFICATIONS: ` (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic-Tank: Distance from nearest well-0470------Distance from foundation-A!t--------------MatpriaL_-----__-_-__- ---___-__-_- ---t„----- �I • " �i No. of compartments-----�'-------------- Size---t_X_�X-�---------Liquid depth---�� ------Capacity---------------#----- ---__-- Disposal Field: Distance from nearest well_/--'�d- _-F_.Distance from foundat1 n_ - �_�__-___Distance to nearest lot line__ ____-------- ---------Len Length of each line_---- 9---0- --------Width of trench-�____-A-,------ � � Number of lines---------`--------- - g �-----------� Total length-------=--�--�----------------------- Type of filter material__f!u-t --_--------Depth of filter material_ __ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits---------------------- material--- ---Size: Diameter-------------------------Depth------------------- Cesspool: Distance from nearest well___________ _____Distance from foundation.__._--------_--_--.Lining material------------------------ ----------------- gals. ❑ Size: Diameter-----------------------------------------------Depth---------------------------------------------------Liquid Capacity---------------------- Privy: Distance from nearest well-------------------------------------------------------------------Distance from nearest building--------_--------------------------------- ❑ ------------------ ----------------- Distance to nearest lot line------------------------- - ---------'-------•---• -- Remodeling and/or repairing (describe):------------------------------------------------ -------------------------------- ------------------------- ------------------------------- ------------------------------------------------ ------------------ 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. _-----_-(Owner and/or Contractor) {Signed)-----,��---�-tl--t--=--�1-s. •_----- --------------------------------------------------------------- -- ------- - ----------------------------------------------- --- ---- --- ---------------------- ------------- - - - (Title)---------- J By: (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 i APPLICATION ACCEPTED BY---- ------- --------- - --------- DAT! T- �.."�... DATE-",?r— ' REVIEWED BY----------------------------------- - % :"" BUILDING PERMIT ISSUED------------�---- - - --- ------ DATE T Alterations and/or ' ------- --- ------ recommendations: ns- ---------- ------------ --------------- ---------------- -------------------- -------------- ------------------------------------------------ ?l -- ---------- --------- ------------- ----------- -------------- ---- -- - ti -------- ------- ------------------ - ----- --- -- ----- -------- ------ —111 wr ktii�i�" �� j- --------------------------------- AL INSPECTION BY:----- ---------F/r-�r� ------------ Date �.� FW -- -- SAN JOAQUIN LOCAL HEALTH DISTRICT 30o West Oak Street 132 Sycamore Street 8I4 North "C Street } 130 South American Street y' Trac California Stockton, California Lodi, California Manteca, California FS-9--2M B-51 Revised W-2100