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1 APPLICATION FOR SANITATION PERMIT Permit No. u (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 wi County Ordinance No. 549. .� JOB ADDRESS AND C ION. �. ' --------'� -------- --------- ---------- Phone-------------------- --- Owner's Name-------- - -- -------------- 4 / _ l ----------- Address------------------------------�•�`� --�r�--- --- --- ------ ------ ------- -------•-• - Contractor's Name----- / ------- Installation - -- Phonelll_^_!_ .�_1_._ Installation will serve: Residence ❑ Apartment House ❑ CommercialAraaiZl r y�rt El Motel El Other El Number of living units: -------- Number of bedrooms ________ Number of baths7slize �� Water Supply: Public system ❑ Community system 0 Private Depth to Water Table 414 ft. Character of soil to a depth of 3 feet: and ❑Gravel EY,Sandy Loam ❑ Clay L am E] Clay ❑ Adobe Er"Hardpan ❑ Previous Application Made: Yes No��New,Consfructioii—1 Yes E] NoFHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ti 4: Distance from nearest well______ ________Distance from founrdation_______-_________-Material-______________________________________________ � No. of compartments---- --------- ---------Size-------------------------- -----Liquid depth--------------------------Capacity---------------------� Disposal ield: Distance from nearest well, ______._Distance from foundation-----�J __ ------ Distance to nearest lot Iins_____ _.-_ y i Number of lines------- ._l------------------Len th of each line---r, -----------____--.Width of french----- _-------.----- --_-- Type of filter material_____�L�of filter material____" _�� __Total length----------- ---___� -- i Seepag Pit: Distance to nearest welf '____________Distance from fo ndation___'y7�_...___.Distan�e to nearest lot iinej_______________ Number of pits v ----------Lining material ��Size: Diameter1. 3 --- c Depth Cesspool: Distance from nearest well-_I--------------Distance from foundation--------------------Lining material----__._-__________.______.________- -', ❑ Size: Diameter----------- -----------i--- - Depth ----------------------------------- -----------Liquid Capacity---------------------- -----gajls.. Priv Distance from nearest well-I_._._____________________________________I-Distance from nearest building-____._______________________.___-_-f - ❑ Distance to nearest lot line-1 ___ ___________________-_---- f Remodeling and/or repairing {describe) - ---------------------- -------------••----•-•-----------------------------------•------------------------ -----------------------------------------------------------------------------1-°---------------------------------------------------------------------------------------------------------------------- ------------------- 4 --------••--------------------------------------------------------------------------------------------------------------------------------------------------------- -•---------------- L ._ -------------- --- I hereby cert' y hat I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ' la and_rules and regulat' ns of the San Joaquin Local Health District. I (Signed �40 _____________ __ Owner and/or Contractor--------- --- .By:-------•---------------------------------------------------------------- --- - - -=-- tie)------- --- -- - -------------------------- ----(Plot plan, showing size of lot, location of system in relation to wells, bue-placed'on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------- ------ - - -------------------------------------'i----` ----------- DATE -- - ----:< -•------------------------- REVIEWEDBY-------------------------------------------- ------------------- _--—----------------- DATE-------{---,-,-- ------i- ----------------- BUILDING PERMIT ISSUED � -------------- DATE--------Cf/---------------------------------------------- Alterations and/or recommendations:----.--- --- --- o -------------T•-V-- ------------------------------------------------------=-•-------------- ---------- ��' � ---...... . . .....?/ � I.� ....L�1�1. '+ Iia-�T7 c T p�� . p_t_T Vii_?' -----------� _t�� .D -?' " ��` . ---------------------------------------------------------- --------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ----- ------------------------------ ` -- Date----------- / -- ---------------------- FINAL INSPECTION BY-------- ------------ l�'��----• -�----------- f.�-��-~-'S--- � ----------- AN JOAQUIN LOCAL HEALTH DISTRICT 4 130 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.