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�r r 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 LOCATJQN_____ ry_ eY G 1 ____ _ }r..-------------------------------------------------------------- -------------------------- Owner's Name____,_ -_--�__Q .A T _ V - -� y - �, p ------------------------------------------------------------------ PhoneQ -(J---b--------- Address--------------�L�'-7!'-7�.=----------------------- -- --------•--------------------•------------------------------------ ----------------------------------- ? YtitQ.,.�------------- ----------------------------------------- Contractor's Name------------- -------------------------------------- Phone------------•----- ----•----- -- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ , Motel ❑ Other ❑ Number of living units: Number of bedrooms -1.-. Number of baths J___ Lot size ..........6-0-A112--- - afer Supply: Public system E] Community system E] Private P1, Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ ClayLoam Clay Previous Application Made: Yes ElNo'm New Construction: Yes ❑ No ❑ El Adobes Hardpan ❑ � ` V� 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___eY ----Distance from foundation----/0--------.Material---- No. of com artments---_ _--- ` '�' p /Z -----Size_Ja-x-?_'__X_16-----Liquid depth-------.. ----------Capacity----1,1 D Disposal Field: Distance from nearest well---/f_ _� Distance from foundation_____l - 14 _-____.Distance to nearest lot line-,--,-I- Number of lines-------------/ --- ---- 1paqk of each line_------ L'7- - Width of french--------02 1--Type of filter material Z'y :_fepth of filter material___----IX-------_-Total length_________ , -------------------N eepage Pit: Distance to neares �,ell_ ______ __ istance from foundation__________.________ ' Distance to nearest lot line_________________ ❑ Number of pits -- ------ ming material atece rial - ----------•----.Size: Diameter----- - ❑ Depth--------------------------------- F Cesspool: Distance from nearest well______ _ - -------- from foundation Lining material------------------------------------- Privy: Distance from nearest weft_ I Size: Diameter--- ---------------------------------Depth-------- ------- ---- -- ---------•----- ---------------Liquid Capacity----------------------------gals. F1 Distance to nearest lot line------ ___ _______- I ___________________Distance from nearest building------------------------------------------ ' ---------------------- -_ -------------------- Remodeling and/or repairing (describe):___- _._-__ -Q _ - i �--• --------------------------------------------------------------------- ----I----------------- -- --------------------- --------------------------------------- -------------------------- -------------------------------- ----------------------------=----------------------------------------------------------------------------------------------------------------------------------- --------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State .laws.and rule and regulations of the San Joaquin Local Health District, Si ned f_./ f [ g , )------ - ------- --1=-------�------'-•=-'----------�__ -----.(Owner and/or Contractor) BY�-----------------------------------------•------------------- ------- 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 APPLICATION ACCEPTED BY_________ �- = -- ------ DATE---- `� =-` � r ------- -------- -� REVIEWED. BY ----------------------------------------- ------------------------------------- ------ DATE- BUILDING PERMIT ISSUED------------------------------- -------------------- ----------------- -- ------------------------------------------------- DATE------ � -----•---------------------------- Alterations and/or re ommendations:__.__-. -- ____ �, --- --------- _ -------------------------------___,..--------------------------------- _------------------- --•---` '._:: ------_.- --------------` ------- FINAL INSPECTION BY:.________-_- + ----------------------- ---- -----•--- ------------ ate-.----------------- --------------------------- -- - ------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 30 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street ,Stockton, California Lodi, California Manteca, California Tracy, California ES_g 2M ` *9-51 Revised W-2100