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}4ai, . APPLICATION FO,.,SANITATION PERMIT Permit No, �1.�7 (Complete in Duplicate) �, Date Issued Applica-1-ion 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"wifh County Ordinance No. 549. JOB ADDRESS AND LOCATION___. 3- --.-` - j Owner's ----- --------••------ -------------- Narne��_`ti-�_.�!_t-~�---•---•r� �1_.__�_----�- ---•--------•----------------------------------- = ------------------ ----- ------------------------------- -=- Address---- .� ) , G ',► T hon ,-fs-- ----- ------ y -•---- -----------------------•-- Name___ � __-_- -__• �'� - --- Contractors� ------------------------------ --------- --------------- - ._.."-•--- Phone--- -- Installation will serve: Residence Apartment House ElCommercial ❑ ❑ Motal ❑ Other Trailer Court S ❑ Number of living units: -----1.. Number of bedrooms . '� c r -__ Number o aths __L_._ Lot size Water Supply: Public system El ',Community system.E] Private Depfh to Wafer Table _ rft. Character of soil to a'depth of 3 feet: Send . -Gravel ❑ Sandy Loam Clay Loam Z� Y ❑ -Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ( New Construction: Yes 0' No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank:: '.Distance from nearest weli-"---------------Distance from foundation_--___-- ^^rt No. of compartments----- ---- Size_ --�... Material ---------------- ----- ----------•----•--Liquid depth------------- ------- Capacity r isposal Field: Distance from nearest well._._.._.__.--- -Distance from foundation .___....._-._.._Distance to nearest lot line_•___.___.______ Number of lines---•---------------------------=--Length of each line-----------------------....._.Width of french iType of filter material--_--.-_- -- v .-r ____"_._Depth of filter material------------- length_____".________-----__--_--_. r ------------ Seepage it: Distance to nearest well----------------------Distance from foundation'___ s--_--_-.,Distance to nearest lot line-,:Number of Pits-------I--------------Linin k material-_-- nne- , --------- g � ' '------Size: Diameter-----V------------Depth...... ....r-2 5 ------------------ Cesspool:. Distance from nearest well"�---------__Distance from foundation-------------------_Lining material---------------------- ,g❑ Size:Diameter-_�_ ®_ Depth- ---------- ------ --- f • - -- --- ---- Liquid Capacity- -------------------•-----.gals. Privy: Distance from nearest well..._..--_--------------- - -------------------Distance from nearest building t �J ❑ Distance.to nearest'lot line--- I - -e-•�.-.---r-.-.. ---- ------- ------ ---•---- -- --- 9 " # --------- ---------------------------------------- -------------I------------------- ------------------------'------------------- Remodeling and/or+repairing (describe): _..._ .mv_ _� - �,� ----------•-- --•- ------- i --------- # -------- ---------- =---------- I -------- -_h e --- = ----------I----------------•- ! hereby certify-fhaf-I have prepared this-application and that the work wiii be done in-a ordinances,' State laws, and rules and regulations of the San Joaquin Local Health District. ccordance with San Joaquin County (Signed)------- ` ` ---------------(Owner and/or Contractor ------------------------------------•------------------ ------------------- (Title)-"�.w`i°-.• c�" ",,`"°-1."'---------------- (Plot plan, showing siz .of lot, loaaion of system in relation to wells, buildings, etc., can 6e placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY---------------------------------------- -------------------------------------------------------- DATE---- ----�.��•- ,.�REVIEWED BY-------------------------------- ----- -------------------------------------- DATE ---------------- BUILDING PERMIT ISSUED------------•----------- ---------- �---- ---------- --- -------------- Alterations and/or recommendations-------------- - --------•_--------------- ------ DATE-------------------- -------------- ------- -------- ---------------------- ---•----------•--------••------- ------•--• -------------------------------- --------------------------------------=----------- ---------------- - •---------------------•-- ---------- ----------- - -------------- FINAL INSPECTION BY------------------- _ �/__9 , ;•Y M __ Date:_ -----. ................ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Syeemore Street 814 North "C" Street Stockton, California Lodi, California Men+eco, California Tracy, California f Es-9-2M 145446 ATWDDD 12-54 d