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APPLICATION IFOR 'SANITATION PERMIT (Complete in Duplicate) Permit No. Date Issued _ 1V1q -_ d _. 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 with County Ordinance No. 549. JOB ADDRESS '-AN. LOCATION---'_--/'- ------- --- 1 -- --------------A------------ '__' Owners Name^--- ------- _ --- ---- ----•--•••-- --------------------------- -_. - _ Phone--------------------U------------ Addresst._(';-_--'l.%I----.1__ = Contractor's Name---- ------------------------------------- '-------- t-------------------------------------------- phone ----------------------------------- Installation will serve- e• Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel �❑ Other ❑ Number of living units: __/___ Number of bedrooms ./'tet- dumber of baths -_1____ Lots size _--I_d0X c� �-i--------------------- Water ------------------Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table _______ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam I] Clay Loam ❑ Clay [] Adobe Z'0<ardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if bim sewer) is available within 200 feet:} t Septic Tank: Distance from nearest well-- ' n erfro found$+ion-_-`-f/- `M�t�e"ri�al________ _________ [ No. of compartments------------ - -----x_$ 0 X -L';1 ';G---- Liquid depth ----- ----------- Capacity ------ -f-�-- t� Dispos�l'Eield: Distance from nearest wel1��__-___-._.Distance from foundationl� Distance to nearest lo�in�e�F_g�_______ " V Number of lines__________ _____ Length of each line. --3®; id#h of trench.________+ ------ ------------ of ----------- Type of filter materiel ,J? _�lDpth of filter mater al_____ ____________Total length_____________�_C 1-6 ---- ____ � Seepage Pit: Distance to nearestiwell_____________--------- Distance from foundation --------------------- Distance to nearest lot line_��_____ _ __ ❑ Number of pits ------- _-------------- Lining material_ ---------------------- Size: Diameter ------------------------ Depth -------------- ----- ,Cesspool: Distance from nearest well ----------------- Distance from foundation -------------- -_---- Lining material ------ ____________.___,.�d___- r. ElSize: Diameter-------- ---------- •-----------------.Depth--------------------------------------------------- Liquid Capacity --- --------------------.-3a s. Privy: Distance from nearest II ------------- __________________________________Distance.from,nearest building________-_______________________�_r_ ._ -_- ❑ Distance to nearest lot line-------- ------ ---------=-------------------------------••-----I---------------------I ------------------------------- , Remodeling and/or repairing (describe):___��'-1 ----------------- - '-____-- _ ____-- __ ----------------- ----------------------------------------------------------- ------------------------------------- `----------- ---------•----- .-_r._ 3 -------------------------------••------------------------ ---------------------------------•------------------------- -------------------------•----------------------------------------=-------------, } I hereby certify that I have prepared this application and that the work will 6e done. in accordance with San Joaquin County ordinances, State/ laws, and rules and regulations of the !San Joaquin Local Health District. (g Si ned A-----4zt (Owner and/or Coneraetor) } --=------------------------------------------- --------------------- ------------------- r By: --- ------------------------------------------ - (Title) (plot plan, showing size -of lot, -location of system in relation to wells, buildings, etc:; -can be placed on reverse side). -� i I FOR DEPARTMENT USE ONLY ; APPLICATION ACCEPTED BY____ _.___ _ _ DATE__- __________________._ REVIEWED BY ---------------- -----------'-------- -------- -------------------------.---------------------- DATE --- -�------------- p }----------- - ------ ---- DATE --- BUILDING PERMIT ISSUED_________________________ __ Alterations and/or recommendations:________________ i_. --------------i } I Il------------ I-------------I----------------•--------------------------------•----------------------------------- I 11 ---•-----•------------------------------------------•-------------------------- ------------------------------------------------------------ I ------------------------------------------- ------•------------------------------------------•---------------- ------ 1 w--------------------------------•---------------- ----------------------------------------I ------------------------- ----------------------- - FINAL INSPECTION BY: ---------- _-- /�----- Date------------------------ ------------ 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 E5 -9-2M , Revises 1-57 F-P.CO. 1"