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1. APPLICATION FOR SANITATION PERMIT Permit (Complete in Duplicate) - — I -- Date Issued .... Application is hereby' 9-- made to the San Joaquin Local Health District for a permit to construct and install the work h.erein described. This application is made in compliance with County Ordinanc No. 549. JOB ADAZESS"AND L90NTI 0 --- ,g -----ji--------------- Owner's Name----------- - ------------------ --- ------ ------- Address..------ - - - ---- -------------------------------- ----- Phone-- -------------,---------------------------- -- -- Contractor's Name__________________ ---------------------------------------------------------------------------------------- ------------------------------_-- ------------ -- --- ---- --- Installation will serve: ResidenceEl , ;------------*----------------------------------------------------------- Phone""--------------------------------- Apartment House Ej 'Commercial El Trailer Court E] Motel ' Other Number of living units:IT- Number of bedrooms Number of ba Water Supply: public Syste, baths Lot size __7 rn E] Community system ❑ Privat 7 . .. ..... ................. Character of soil to a depth of 3 feet:; . Ou Depth to Water Table -------- ft- Character S El Grave) Ej Sandy Loam 0 Clay Loam E] Clay F Previous Application Made: Yes 0 [1 New Construcfi -1 Adobe C] TYPE OF INSTALLATION AND SPECIFICATIONS: on: Yes ❑ iy (No septic tank or cesspool Permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest.well I Distance from found ption tion_--_/"0---- ---- --------- Liquid depfh (._ Capacity- -------------------------- No. of compartments Mafer*aI Disposal Field. Distance from nearest welt_. "---"Distance from foundation---- Number'ojr fines_______-_ ength of each line 7,,g-7 ------- Distance to nearest lot Ii6e --'�------ (T Width of french.-_-- Type of fitter material---- ----------------- -Depth of filter material-_." ------------Total length------- Seepage pit: Distance 'to nearest well------Zo Number of 0s---------I-----------Lin i.n-g r�naferiaJ------ gn ou Distance to nearest lot line----- ize: Diameter' IL ------Distance fro f ndation_,'_/P_ Cesspoo�: Disfance:frorn nearest weil S Diameter____-"""- ,Fr---- __Depth-----------40-f-------------- 171 Size, Diameter--------------------------------------Depth------------ --Distance from foundation--------------------Lining material-.. ------------------------------------Depth------------- ------------------------------ -------Liquid Capacity------material_.._____._____ ❑ Distance from nearest well--------------------------------------- -------- Distance from'nearesf building ----------------------gals. ❑ Distance`fo nearest lot-line ----------------------------------- ---------- Remodeling and/or repairing (describe}:------- --- •- , ----- •------•------•----------•------•---------------- describe)--------------------------------------------------------------------- ------------- --------------- - -----------I---------- ----------------- .. - ------ ------------------------------•------•--•--- -------•------- -------------------------------------------------- -----------------P_Z? ---------- ----------- --------------------------------------------------------------------------------------------------------- --------------------------------------- -------------------------------------------------------------- ---------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, a d rules and regulations of the San Joaquin Local Health District. (Signe cr?<_----- - - --------4'V_ --------- By_____________-------------............... -- - -----------(Owner and/or Contractor) _---------------- -----------------------------------------------------------------------------------(Ple)-- 11 ----------------------------------- ---- - of Plan, showing size of lot, location Of system in relation to wells, buildings, etc., can(Titlbe placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_____________""- REVIEWED BY-------------I ------------------------------------- BATE------ BUILDBUILDING PERMIT ISSUED_ ------------------------------------------------------------------------------- dATE __-------P----- ING ------- -------------------------------- Alterations and/or recommendations----------------------------------------------------------------------------------------------- DATE----- --------------------•----------------- ------------------- -------------- ------------ ------------------------------------------------- ------------------------------------------------------------------------- �- -------------------- --- ----- ------ ------- ----- ---------------1, 5 ------ --------------------- - ------ ----------------------------------- ------- ---------- ------------- -------r------- --------- --------------- ---------- -------- ---------- --------------------- Ile--------------------- ----- ----------�7 ----------------------------------------- ------------- --------------------- ------------------ -------;�t--------------- ------------------- - ---- ------------------- a '17-------- --- --- FINAL INSPECTION BY: --------------- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street Stockton, California132 Sycamore Street $14 North "C" Street Lod;, California Manteca, California Tracy, California E5-9-2M 10-52 Revised W-2)00