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1 APPLICATION FOR SANITATION PERMIT Permit No. 1/ . . ��ry /1 [Complete in Duplicate) Date Issued - '� - Y rW`� h :y .... r.!w-.,�eW��+�✓•w rNnN•..�-J'!"!P'n C,wT•„w'x'•` +,,,s+r- '. 'fie -- p .:.. €:,�-�•.nr' r kt r r � f i'1 *: ..,�� Application is hereby made to the San.Joaquin Local Health District fora permit to construct and install'the`work�iaerrtestnloeh. This application is made.in compliance with County Ordinance No. 49. JOB ADDRESS AND LOCATION.--- � jPhone-------------------- ---•------- Owner's Name__ �✓�' y. Address ---'------ -- - =;� itf .,✓�J/� Phone Contractor's Name----"-� { = --------------------- --- - ,. Installation will serve: Residence . ' -1, partment House ❑ Comme,rcial ❑ Trailer Court❑ Motel ❑ Other ❑ Number of living units: _�..__ Number of.bedrooms'_R-__ Number of baths __/__ Lot size2-----______- Water Supply:: Public system . Commun'ity'system ©1 Private ❑_. Depth to Water Tableft. _� . Character of soil to a depth of 3 feet:. .Sand ❑ Gravel [) Sandy Loam ❑ Clay Loam ❑. "Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No ( New .Construction: Yes ❑ No I� FHA/VA: Yes ❑ No [ � TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if,public sewer is available within 200 feet.) p y No. of compartments------ --------°�--Size- -1-- Liquid depth--------------------------Capacity---------------------- N - -- -- a Se0i Tank: Distance„from,nearest well-----------------Distance from foundation'_________________ __Material------------------------------------ Dis . Field: w. Distance from nearest well_________________Distance from foundation-------------------_.Distance,to nearest lot line---',___:-______- '� Number of lines Length of each line------------------------------Width of trench---------------------------- Number Type of filter material_________________________Depth of'filter material______--_______-______Total 'length-_-____________._______-____':______•.--.- 1 A R ., 7 Seepage i}:- Distance to nearest well-Air --___Distance from foun ation.__r+ _�______.Dist�7ce to nearest lot line___ _____ I, ize:'Diamete g___ 1 Number of•pits_ Lining materiae_ . tJ Depth � =------------ , Cesspool: Distance from nearest well------------------Distance from foundation_:__:.__---___..___Lining material------------___._-__.__ _____-_______. '� ❑ Size: Diameter-----------------------------------=-Depth--------------------=--=---------- -----------------Liquid Capacity-------------------- ---gals. rti Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__.__________.____._______ ❑ Distance to'nearest'lot line------- ----- I ------------------------------------------------- =----`--'--------------- -----------------=---------------------•--------•-- _-------•- Remodeiin' and/or repairing describe „� •- a --------------------•---- ----------•------- -------------------------------- -- ---- ------- ---------------------------- ---------------------- - . . 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, and rules and r gulatio is o the San Joaquin Local Health District. `�-t ---------------- �. r C ra E Si ned ont ctor) { - (Title) --�, By�----=--•-- ---------•----------- •------ -=----------- ----- [ ) _ (Plot plan, showing size of lot, Iota of system in relation to wells, buildings, etc., can be placed on reverse e). . }, ” T FOR DEPARTMENT USE ONLY z APPLICATION ACCEPTED BY ''= - -.---------- ----------- -------- DATE ----- ------- DATE---- ---- [ ` -- e REVIEWEDBY----------------------------------------------- -- ----=- ---- ---------- 1__._.... 1 BUILDING PERMIT ISSUED------------------- -------------------------------------- DATE =' �______________________________________________________ _•________..•________...._-__________� � Alterations and/or recommendations-------------- -- -- ------------- ------- --------------•---------- --- --- -- ----------- ----------- ----- ----- -- . ------- ---------------------------------------------------------•------------- -- ------- ----------------------------- -------------IF i __________---------------_--- ________________ ____ { _______________ FINAL INSPECTION 'BY: . :. ' --- -- -- - -- - ___- ---- Date- ----__-- - SAN JOAQUIN L L HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore 5tree+ 814 North "C" 5+teat a Stockton, California a Lodi, California .Manteca, California Tracy, California ES-4-21x1 . Revis_ea,1,„ 7-..F'-,P:C0. -