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r APPLICATION FOR SANITATION PERMIT Permit No. � _- s (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- ego - G ;__ �Iz_/, . ---. ------� -------- ---------------------------- Owner's Name--- -�� '' ^"^��-------------------------------- Phone___{_'--- =_�- 4 r Address----- - x, 1- ............ f --------------------------------------- ------------------------------------------------- ---------------- lop' Contractor's Name_e'.2r��----------------------- -' -------------- Phone----------------------------------- Installation ----._.----------.----_---_Installation will serve: .Residence P Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 1------ Number of bedrooms _- - Number of baths _�----- Lot size -_� .______.; z-sr� - _ ----------- Water Supply: Public system ❑ rCommunity system ❑ Private P' Depth to Water TableC6--- ft- Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan,t {! Previous Appli ation Made: Yes,[]_No ® New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is-available within.2004eet.) w. — Septic Tank: Distance from nearest well:+_ :_Dista'ce from foundation"--' '_.. _....Material---------------------------------__ No, of�-compartments..._2^__ _ --.-..__Size_��a�'-_� _----.-__Liquid de th-_- _ -_. Ca aci �4 O c�� Disposa3 Field: Distance from nearest well--50---------Distance from foundation__ 4----_____-_.Distance to nearest lot line___._--.__ ( ] Number of lines-------�-------------------------Length of each line--S -------------------.Width of trench-l-�y-------------------__-- ;, Type of filter material,—______Depth of filter material_-l��'-------------Total length__s7�_*_________.--_-------_---_____-_ Seepage Pit: Distance to nearesf�well_1o_C?-----------Distance from foundation--_T ____...---.Distance to nearest lot line-- �] Number of pits----�----------------Lining Diameter----13*----------- Depth---x•.17-!------------------- 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------------------------------------------ Distance _________._____----_-_-___-_------__---- Distanceto nearest lot line----------------h=--.----------------------- - ----------------------------------------------------------------------------- ----------- Remodeling and/or repairing (describe)------------------------------------ ---------------------------:----------------------------•-------- ----------------------------------------------- s ___________________________________________________________________________________________________________________________________________'-._________--_-.______--____-__-------_.--__.---______________________.___-_---- ------------------------________________________________________________________________________ ------..._._.----------------------_._-_-------___._.____-_--_-__-----_-______--__-___--_-----------_----___-_-__---- I hereby certify that I have prepared this application and that the work will be`tdone in accordance with San Joaquin Count ordinances, State laws, and rules and regulations of the San Joaquin Local Hbalth District. w (Signed}_ .tt '1 - - --- (Owner and/or Contractor] By:------------------------------------------------------------------- ----------------------------------------------=- -(Title)-------=_------------- -------- ------------------- e .=:__:_.: �- (Plot-plan,'showing size of to+,-'location of sys`+em in rela4ion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY . .- -'-� �-- ----- --------------------------------------------------------- DATE-�_- � `7 -- ---- -------------------------------- REVIEWEDBY------------------------------------------ -- --------------------•----------------------------------------------------------- DATE----------------------------------------------------------- BUILDINGPERMIT ISSUED-----------------------------------------------------------------:---------------------------------- DATE-•--------------------------------- Alterations and/or recommendations: . recommenda-t-iovns�s-�--,-'a------ ------- -�-'--------------------------- -------. .-- _ r n----------------- • - ---- -� ------------- - ----- ----------------------------------------------------- - � .---------._ --------------------------- -------- ---------- --------------------------------- I----•------------ f ' FINAL INSPECTION BY: '------- ----- Date. -------------------------------------------- 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 Revised 1-57 F.P.CO_