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APPLICATION FGr SANITATION PERMIT Permit No. i r (Complete min Duplicate) Date Issued _-" k Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicafion..is made in compliance with County Ordinance No. 549, i S. -. ' ' _ F JOB ADDRESS AND :.OCATI N--- -------- -- - i----- - - ------- ----7�4__ a ------------------..---=----------------------. i 'Owner's Name.------ ----------- " ----- -------- " ,-----------------------------------------------------. Phone------------------------------------ Address----- ----------------------•-----------•Address_____ —.- - --------- ------- -------- ----------------------------------------------------------••-------------------------------------------- ------------------------------•- Contractor's Name----- - "--------"--------------------------------------------------------------------- Phone_6:7 99 _6.2,--- r # Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Co art ❑ Motel ❑ Other ®' Number of living sanits: 'Number of bedrooms:------- Number of baths -""_-_- of size _--------_-.-------_-----------------_-------_-----I L ..-"._ Water Supply: Public system ❑ Community system ❑ Private C3/bepth to Water Tablez-- ft. I Character of soil to a depth-of 3 feet: ' Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe [hardpan ❑ tPrevious Application,Made: Yes E] No [D,,'_Vew Construction: Yes 2?-<o E] FHA/VA: Yes ElNo ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: ( (No septic tank or'cesspool permitted if public.sewer is available within 200 feet.) // , - Septic Tank: Distance-,from nearest well/�---" .-_-Distance from foundation_-3-d-""-_._.-.Material-""--- """--- ."_:." ".."-""__--------"--.----. t}J, 2 No. of compar+merits--,_----------.-..-"Size___'��'�__��_______________Liquid depth""-"Ll .-.--"-"-Capacity." .. `.,� t i, Disposal Feld: Distance from nearest well-AD--------.Distance from foundation,,5 _--_-�-Distance to nearest lot lin�_ Number of lines""_.-------------- ------" Length of each line/ _--r ""_/,3-Q_--.Width of trench---" "--__"__: I Type of filter mate Seepage of filter material----a-" -�,----Total length"-- - - "�---------------------- 0 Seepage Pit: Distance to nearest wel _ -----__Distance �m f' ndation" _""_" Distance to nearest lot line-_-' [ Number of pits-____f--------------Lining material-__ -6"` -Size: Diameter-_ _3_____-__-___Depth___,1 *---- Cesspool Distance from nearest well----------------Distarice from�foundation--------------------Lining material_.--------.--------.-----_----.---.- m°° Size:,Diameter- -----------" _ Depth------ -1--"--------i--------------------------------Liuid Capacity gals, Privy: Distance from:nearest well--------------------------------------------------Distance from nearest building------------------------------------------- :' ❑ Distance to nearest lot-line."------------------------------- ---•-------=------------------------------------------------- -----==-- --------------------- Remodelingand/or repairing describe :--. 7" ^"___ _-_""- __ "____"__ _.--- "- - �__ _ ---- - . 4 -----------------•----------------------------------------------•--_------------------------------_----------------------------------------------------------------- =f -- - -------------- ----------------------------------------------------------------------------------- --------------------------------------------------------------- ---------------------------------------- 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinancek-6V laws, and.rules and regulations of the San Joaquin Local Health District. r (Signed)----------I-AA + ---- -=--- - --------= ,-------- ------------------------------------------------ --- --(Owner and/or Contractor) By=------------- ;;------------------------------------------------------ (Title)--- `--------------------- ---------------- (Piot plan, showing size of lot; location of system in relation o wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-------------------- DATE' REVIEWEDBY -------------- - ------ - ---- ------------------------- DATE --------t ----- = BUILDINGPERMIT ISSUED----------------------- ------------------------------------------------------------- ---- DATE._------------------------------------------- --------------- Alterations and/or recommendations------=--------------------------------- ----"---------------------------------------------------------------------------------------_------------------------ r .---------------------- e --_-•----•--------------------------•---_�----------------------------------------------------•........... ......"-.""-._.-.--_._""...-. --_----_---------------._.. ------------------------------------------------------- =-------------------------------------------------------------------- ...............".-..---------------------------------------------------------------------------------------- 1 I FINAL INSPECTION BY:--------1.,/---'r----------------------------------------- Date---------7--"x- - - 1 I SAN JOAQUIN LOCAL HEALTH DISTRICT 1 1' 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES---4-2M Revised 1-57 F.P.CO.