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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in'Duplicate) Date Issued ------ -��J---/-- 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 compliancg�w•t oun O-finance No. 549. JOB ADDRESS LOCA ° ------ --- '" ------ - ------------------------- P ---- --- -- _ Phone----••------------------------ Owner's Name ----- -- --- -- --- -- ------ Address -------------------------------- -: --- --------- -- ---------- --- ------- Contracfor's Nam e± = ( __ •- -- ---------- --- Phone__..-----•-•------------------- Installation will serve: Residence Apartment House E] ommercial ❑ Trail r Court ❑ Motel ❑ Other ❑ } Number of livi"ng units: Number of bedroomsUa*u ber of baths 1 ir Lot size -- _ .16-_-----•------•---------- --- [_ Water Supply: Public system Community system ❑- Private-❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: SandFj Gravel ❑ Sandy Loam Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ FHA/VA: Yes ❑ No ❑ t TYPE OF INSTALLATION AND SPECIFICATIONS: E (No septic tank or`cesspool permitted if public sewer is available within 200 feet) rr Mate i I - ------------------ - Septic ank: Distance from nearest well__ _ Dist riyg fllrorp/Bund tionl-_ ___ i No. of compartments iz _!_11Q-a+ /r;Liquidepth ' Capacity-- r .. P Dis os8 Field: Distance from nearest well___ _ _ _ __Distance from foundation___ ___ _ ______ C f �_ � - • .�d��Distance"to nearest-lot inl!��,,C/`Y�'�D�, Number of lines____:___-_ _ ''`_ Length of each Gne �<-- _ Width of trench__________ 7� G -- �] Type of filter materi_ _ w -- -- -----Total len ___� _ th"of filter matersaL-::: _ � gth___.____ Seepa e Pit: Distance"to nearest well_ _ _ .___Distance foundation____1-D.......__.DistanCO to nearest lot line__i}_________ Number of pits___ Linin- materia Size: Diameter____'3__'3_-1 Depth--. r ________-_ fCesspool: Distance from nearest well---------'---._Distance from foundation--------------------Lining materia l------------------------------ -____. ---Depth--------------------------------� -----------Liquid Capacity--------------=------- ---gals. Priv Distance from nearest well______ p # v# y• ------------------------------------ -Distance`from nearest building--------1------------------------- V ❑ Distance to nearest lot-line------ ------------------------------ ------------------------------------------------------:---------------------------------------------- a a r � - eeiin and/or re aid_ scribe:----- ---- ��.A.�---- - --------------------- m $ -- --- _`' -'-r I --- -- -- ---------------------------------------------------- r -------- -----------------•------------------------ -•-•--------------------------------------------------•- -------------------------------------------------------------- R -- I hereby certify that I have prepared this application and.fhaf'the work will.6e done in accordance with San Joaquin County ordinances, State las, and rules and regulations' of fhe,San Joaquin Local .Health District. , (Signed)-------- -------- ----------------------- -- {Owner and/or Contractor ---------------- By:--- ------------57 ��: .P----_-- (Title) (Plot plan, showing size of lot, locati of system in relation to wells, buildings, etc., can be placed on reverse side]. F ® ,5 FOR DEPARTMENT USE ONLY' APPLICATION ACC>_PTEI731BY_ • __.--r---_- � DATE--�,---•-• REVIEWED BY -=f '-----------=-------------------------- DATE . BUILDING PERMIT ISSUED----------- ------------- -- 4 -------- ------�-{----------------------------=--------- -- -� DATE------� • -----------=------------ -------;-••------• , r a .. �y. r <% Alterations and/or recommendations:=-==-----'----------- ------ •-----------------------------------------..----------- - - ------------------•-•----------------------------- 1 -------------- k ------ c --------------------- ._ ------------- --- ------------------- --- ----- - ::::::::::: FINAL INSPECTION BY::__ �-__ �'= _,_ Date__ r -7 ---- 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.