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APPLICATION FOR SANITATION PERMIT Permit No. __1__I___ ---------- (Complete in Duplicate) Data issued Applica-lion 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-------------4 N21-----------e�--- ----------------------------------------------------------- Owner's Name ' ---------- -------- ----------------------------- ----- -------- Phone------------------------------------ Address.. hone------------------------------------ Address........---4_a--- - --------------------------------------- --------------------------------- ------------------- ----*ed ----------- Contractor's. Name------- ---- --- —------------------------------------------------------ Phone ----------- ------ ................................... Installation will serve: Residence Apartment House E] Commercial E] Trailer Court F] Motel F] Other E] Number of living units: _/__-__ Number of bedrooms Number of baths ___k Lot size ---- 40 - - -- -- --------------------- WOer Supply: Public system [] Community system E3 Private A Depth to Water Table ft. Character of soil to a depth of 3 feet:.1 Sand [j Gravel [] Sandy Loam 0 Clay Loam E] Clay [I Adobe a Hardpan ❑ Previous Application Made: Yes E] No [� New Construction: Yes EL No E-] TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest ....Distance from foundation-----1-0--------Maferial-,e.e--- ---------- No ,of compartments-------- ;2 1----------- ---Liquid depth-------Z,,7-0 ---------Capacity------91-—------- Disposal Field: Distance from nearest Distance from foundation---:7-W------Distance to nearest lot line---iP 0. NAber0 1 lines----------- --------------Length of each line----------1,3-------------Width of french------=t� -5------------------- Type of filter materia.110 �ei---Depth of filter material- length---------/�--- --------------- Seepage Pit: Distance' to nearest well--Je-w ----Distance from Distance to nearest lot line------ Number ofpits------ --Lining mate ria Ie--C�i4: Diameter— -3-----9- ....Depth-----_ 01 Cesspool: Distance from nearest well-----------------Distance from foundation--- --- Lining material-------------------------------- El Size: Diameter--------------------- ----------------Depth-----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest weft_____________________________--------- _________Distance from nearest building___.._._______----______-. ❑ uilding------------- -------------F-1 'Distance to nearest lot line_________________________. Remodeling ine.........----------------Remodeling and/or repairing (describe]:--------------------------------------------------------------------------------------- -------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------I------------------------------------------------------------------------ . .1 ----------------------------------------:------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------- ------------------------------ --i-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances. Ste Ws, and rules and regulations of the San Joaquin Local Health District. (Signed)..--- ------ ----- --- -------- ------------------------ ----------------------------------------(Owner end/or Contractor] 7421� 117 -----------------------------(Title)--- ----------------i-1------------------------------ (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 - -------------------------------------- DATE REVIEWED BY------------------------------------------------ ---------------------------------------- -�4 -APPLICATION ACCEPTED BY-- ---------------------------- --------------- - -------------------------- DATE--------------------------------- --------------------------- ----------- BUILDING PERMIT ISSUED--------------------------------------------------------------- --------------- DATE..----------------------- Alterations ATE ----------------------Alterations and/or recommendations:------ ---------- .......... ........... ----------- ----------------------------- �- - ----- ----- 7----------------------- -------------------------------------------------------------------- ------------------------------ -----------;P- ---------------- ------------------------------------------------------------------------------ -- ------------------------ -----------L--------------------------- --------- -------------------------------------------- ----------- ——----- ---- ------------------------------------------------------------------------------ ------------------------------------------------------ -------------------- ------------------------------------------I——---------------------------I--------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 E5--9-2M 145446 A7WOCO 12.54