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f s7 fc�q/ APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued _____ Applica+ion 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 .SA ,.-x_CAI /V G72-7TZ------------1.A!' Owner's Name---- - -1 ----- - ~---------� ----------------------- -------------------------------------------- Phone-- ------------------•---------- Address--------------F a.t....9cx--------Il cy-------------`S r� e ^-7-e- _C- _K7`1/ Contractor's Nama------------------------••_} -------------- ---------------- ---••--------------------•-- Phone-Ha -!F.6 4.7 D---. T Installation will serve: Residence ❑ Apartment House ❑ Commercial [X Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __—_ Number of bedrooms ---==- Number of baths __-___ Lot size -6----11V -/1_1E S------- 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 ❑ AdobeX Hardpan 0 Previous Application Made: Yes ❑ No New Construction: Yes ❑ No D� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: do Distance from nearest well-___________.___Distance from foundation-------------------_Material----------------------------------- ❑ .,,,3V No. of compartments---------- ---------------Size--------------------------------Liquid depth-------•------------------Capacity----_-- Disposal Field: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line--------.________ ❑ Number of lines-----------------------------------Length of each line---------------------------.-_Width of french---------------------------------_- Type of filter material________________________Depth of filter material,----------------------Total length-------------.__-_____________-_.--_______ Seepage Pit: Distance to nearest well__1V1zA1E--__._--Distance from foundation___. f ..___.Distance to nearest lot line_,_/,57_.0 . f' V( Number of pits----Q_PVE-------Lining material___ --Size: Diameter__."�J__�____..___ ___Depth__��_�___________________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-_.___________._____---__________._. ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------Liquid Capacity- --------------------------gals. Privy: Distance from nearest well ____-------------------------------------------Distance from nearest building----------------------------.--________._. q ❑ Distance to nearest lot line---------------------------------- -------- Remodeling ------Remodeling and/or repairing (describe):_. -- - ----------�"'� . -.,L'�r•.--- -------'------•----------•----•------ -------------- = -- ---------- ' � _ �- ?. '��, - _._. ' -------------------- ------------------------------------------•-- -------•--------------------------------------------------•-------------------- -------------------------------•------------------------- ------------------------------------ --------------------------•-----------------------------------------------------------------------------•-------•--------------------------------------------------------------- I hereby certifethaf ave prepared this application and that the work will be done in accordance with San Joa uin Countyordinances, State lrules and regulations of the San Joaquin Local Health District. (Signed) l ;-•----------------- ---- {Owner and/ Contractor) f; By: ----------- ---- t E�..(Title)- ' [Plat plan, showing size of lot, ocation of system in relation to well , buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ------ DATEL---------------------------------------------------- -- --- ------------------------- - ------------------------------------ REVIEWED BY - ------------•------------- DATE----��c--- BUILDING PERMIT ISSUED_--------------------- -----•---------------- ------------•----------------------------------------- DATE--------SZr - - - - - Alterations and/or recommendations:-------------------------------------------------------- •--------------------_----•---- -•-------------------••---- --------------------•---------------------•---------------------•------••-----------------------------•----•----. --------•-------- -------• -----------------------•------•-•-----------------------•--------------------------------• •--------------------------------------------- -------------------------------------------------------•----------- ----------•---•--------------------- ------ •----------------------------------------- ------------------------------•-------------- ------•--- ------•-•---------------••----------------------- -•---------------- --------------------------••--------------------•---------- --- Date_ FINAL INSPECTION BY:.--------:._._;-=�14='=f''�-�------�----- - ------- -- ,�--�� --------------------------- ------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9--•2M Revised W-2100