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1010'1 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) EXPIRES ONE YEAR ]wRO' aIssued'��i I}� TEApplication is hereby made to the San Joaquin Local Health District fora ork herein described. This application is made in compliance 1with County Ordinance No. 549. JOB ADDRESS AND LOCATION;' d� -6_�p =-----------------• -------- ----------------- ------------------------------------------------- Owner's Name ---------` ------ Phone ---------------------------- Address----------------- ------ ----------------------- '9'��'�J-- --------------------------------------------------------------------•------------------------ Contractor's Name---- - - .--------------------- ------- Phone ----------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: __ __ Number of bedrooms 2! ---- Number of baths -_k____ Lot size -----6 X____4_jf--------------------- _____ Water Supply: Public system 5;�ommunity system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Q---H-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 public sewer is available within 200 feet.) w: Septic Tank: Distance from nearest well____ ___________Ristance from -foundation -------- _!___------- Material --- .----------------------------- .__..______.._.. �^ No. of compartments----- ------------- Size ---------------------------- --- Liquid depth -------------------------- Capacity --------------- j Disposak Field: Distance from nearest well')1�__ Distance from foundation__ Aq Distance to nearest lot line ... ,__._._. Ela' Number of lines---------`_,-___'____-.'----------- Length of each .line _------ �_0--------------- Width of trench--_-a-�f _--------------- h - t+r Type of filter material-__--`�.r�s�.------- Depth of frlter material___�_�i______________Total length ------- _ _V______.______________,______ i I, t 1 t See a Pit: DN�umbee to of nearest well--_) vKk,_--__Distance,�fr_omf,foundation___,�i2_______..__.Distance to nearest'lot i npe_____________ ' ______Linin material_ lwXA.--_______Size: Diameter____ 3______..__ Dept h-.-- . 2_s ------------- t.' '` L' ' t _ _ I esspoo: s ante iom neares# we _________________ Size: Diameter ---------- ' -------------De is once rom oun a on...._._...__..,. ening ma eria ___.__._.________________._._________- Dept Li , --------------------------i-----------------------uid Caaci} p`r.. 1q '14i Capacity 1 ----------------------------�ale. ! i Privy:Distance from :nearest well___________________________._______._____._____._Distance from nearest. building_______________________-__ _______._. ❑ Distance to nearest lot I'ine - `=--------=----------------------------------------------.------ y d Remodeling and/or repairing (describe):____--.-_.__'__..___._ �•cr.7.A.0 ''4^ - - ---- j -- -- Y- _ - - _ ------ --•-----------------------------------•--------------------------------------•-----•---------------------------•- -----------------------•-------_----------------- --------- -------- ------------ --------------------------------------- ----------------------------------------------------------------`--------------------------------------------------------------------------------------- ---------------------- ----- ---------------------- ------------------------------------------------------------------------------------------------------- ----- ---- ----------------- --------------------- - - 1 hereby certify that I have preparod this application and that the work will be done in accordance with San Joaquin County ordinances, State la and rules and regulations of the Sa Joaquin Local Health District. r. {Signed) --------- k -------------------------------•--------- {Owner -Contractor) �. ----------- By:--------------------- •--------------------------- -----------------------------------------------------------------------.--(Title). '+`'=-------------- ---- (Plot plan, showing size of lot, location of system in .relation to wells, buildings, etc., can be placed on reverse side). ; a u E '- f FOR DEPARTMENT USE ONLY+ . APPLICATION ACCEPTED BY ;= - �tl�. ��^�----------------------- DATE I-7 js%------------------------------ REVIEWED ------------------------- REVIEWEDBY---------------------------------=`------------------------------------------------------------------------------------------- DATE ------------------------------------------------------------ BUILDINGPERMIT ISSUED ------------- '------------------------------------------------------------------------------------------ DATE-------------'-------------------------------------------- Alterations and/or recommendations: ---------- .-----------_ --.-� ` -------•--------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------ I! ------------------------------------------------------------------ ---------------------------------------------------------------------- -----------------------------------%;------------------------------ ---------------------------------------------- •------------ ,-------- ------------------------ ---•----------------------------------------------------------- •------- •------------ •-•------=------------- 1-1 ---------- 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 ES -9-2M Revised 1.57 F.P.CO.