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1F ,_ 1_•Y• APPLICATION FOR SANITATION PERMIT Permit No, (C mplete in Duplicate) /a J / �al h•� Date Issued ______yl_.y�'/- 3� A lication is hereby made to the San Jo Judi ) pp y q n HeIt District for a permit to construct and 'install the work herein described. This application is made in compliance with County Ordinance No'. 549. r. ► JOB ADDRESS AND LOCATION---/�----4� l= _�tc� = ' .cU v . : ' T ="`=� f�� Owner's Name -- ---------- = -- --f - ----- ------------ Address--- Contractor's / _ �: Phone. 4 -t_ l ral� Address f --•-•-•--; Contractors Name------ ----------- 1�- v =A ----------------- ------ Phone--- �,.�, Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer- Court ❑ Motel El Other Number of living units: ____ Number of bedrooms___ umber of baths -- Lot size __ _°_4 _--- _( :t�___________________ .. . Water Supply: 'Public system [] 'Community system, . Private ❑ Depth to Water Table Character of soil to a depth of. 1'feef: Sand ❑�-G~ravel E] Sandy Loat�i ❑ Clay Loam E3 Clay Adobe[7 lardpan ❑ Previous Application Made: Yes ElNo"❑ New Construction.- Yes No ❑ FHA/VA: Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: • " (No septic tank or'cesspool permitted if public sewer is available within 200 feet.),A Septic nk: Distance from nearest well__ _0_______Distance from foundation___�_!.�__..:_____.Matepal_f__--- -_i______--- _-'--j- :�---- - No.'of com artments__. f� P Size __X.- �� Liquid clCapacity--- t reld: Distance from nearest well__e -------_.Distance from-foundation:__J U_______-Distance to nearest lot line_____________ Number-of lines_____;_____.Q�_______________`_Length of each line_____r Width of trench___ ___f� - --------- - ` Type of filter material---1/✓_4�1 _._`Depth of filter material_ �_`_':__Total. len th`:_ � ______ g -- " See a it: .Distance to nearh rest well 7J_Q_P------------Distance from foundatian__��.__�.__�.: P g _ r � Qisfi ce�to nearesfi la-�line____.�_____..._� Number of pits-----+� ------Lining material-----Y'_(2.4-1�_-_.Size: Diameter__.-----7----------------Depth__-- - .,.�7_!______________ p ___ _.,'bistance from foundation Y__________________Lining material__---___._______ 7 -------- Cesspool: Distance from neaire�t}well____.__ De th______._____________ � - r : ❑ Size. Diameter------- --.--"---------. P -------------------------- ---Liquid Capacity--------------------- ---.gals. Privy: Distance from nearest'w'ellf'__.!_ ________________________--.__---___.__ _ ._Distance from nearest building-.-___ _-'_-_._________.________---------� ❑ -Distance to-nearest-lofdine--------- ------------------------------------------==----------. ------------------- ---------------------------.+ ,. Remodeling anti/or repairing(describe}: ____ ✓' . rte ~ __ --------------------------- ---------------- --------- -------------------------------------------1�- -------=------------------ ---------------------------------------------------------------=-------------------------------------------------------=-------- - -------------------------------------------------------------------------------------------------------------------------------------------------------- r 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, andKlesanre afions of the San Joa uin Local Health District. g - qSi ned{ 9 }------------------- - ' --- ---- --- - ------ - - �------ -- --- -------'------------- --------{Owner and/or Contract By: - Ll: -� - -----------------{Title} =!� (Plot plan, showing six o ot, location n of system in relation to wells, -0 din s, etc., can be laced on reverse side). -- ---"---FOR DEPARTMENT USE ONLY' `. APPLICATION ACCEPTED BY- - - -r---------------------------------- - ----------------------• ---------•---- DATE S. REVIEWED BY --- ----------------------------------------------------------- DATE._ yx ____�_-------------------------------- -------------- BUILDINGPERMIT ISSUED---------------------------------------•-------{----------------------------------------------------- DATE--------- --------------- ------------------- -------------- ` Alterafions and/or recommendations________ ______________________________-- ---------------------•----------------------- ------------------------------------------------ ------------------------------------•-------------------._...------------------------------------------•---------------- : . - / ---------- ---------------------------------- FINAL INSPECTION BY:------ i �r a_` ^— ----------------- Date -t��f J 7`' 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 ES-9-2M , Revised 1.57 F:P.CO. ir-