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it APPLICATION FOR SANITATION PERMIT Permit No, .- (Complete in Duplicate) Date Issued f 3�S q Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. 3. This application is made in compliance:with County Ordinance No. 549, JOB"ADDRESS AND LOCATION.___!_____4� +� -?� �f IC Owner's Narr!er1s" �- -------- / ��_Address---------- Contractor's Name - ''.�1---------- - � �y --------------------------•-•----------------------------------- i ------. FF�-----6% `L 6%1C � C'1_--------- ' - - --------- ------------- Phone Installation will serve: Residence Apartment House❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: _. Number of bedrooms _._ Number of baths ____--_ Lot size _____x-ax Water Supply: Public system Community system ❑ Private i ❑ Depth to Water Table ft. . a � Character of soil fo a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9,-�Hardpan ❑ Previous Application Made: Yes-❑;*�No E!r' New Construction: Yes ❑ No [-_"1HA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: _ i (No septic tank or"ces spool!permitted if pub'M sewer is available Fwithin 200 feet.) Septic� gnl}I f� "tante from<nearesr well__ .___stance fr m foundati 1 ��.------.Mate .No_of compa`itments'_.____� ' ----Size________ X-- N,Sr i �d depth-- 'i`------- ----Capacity Dispos Fie d:ati Distance from nearest well___. eDistance from foundation_:_ "t I—. _ ._.Distance to'nearest lot lm _____________ EV N. Number of'lines ��__--______� _ - Length of each iline_-.-.-1 __r.��- WidthGo trench.__ 1 � .: Type of filter material___ __Depth 'of" filfei•"materiaL__a '_'- i Ip" -----Total length---- off--------------------- Seepage`Pit:t} Distance to nearest.well ___________Distance from foundation_;_.________-__.__. istance to nearest lot line_______________.. ❑ � D G1 L. Number of pits---- .------- Lining material---------------- ------Size: Diameter------------------------ I t� Depth :;w , Cesspool: Distance from nearest well--------------___Distance from foundation--------------------Lining material------------------------------------- El 1I p Liquid Capacity--------------------- -- gals. ti Size: Diameter------=--------------- -------------De th-----T------------- �f Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------------------------- El Distance to nearest lot line--------------------------------------- --------------------------------------------------------------- - ----------- `• Remodeling and/or repairing (describe)--------- ----------_ t,'y -----------I -------------.1 ------------ - ------•-------- i ____________________________ _________________.________________._____._r_______________.__-_____________-_________-________________________________________.____________________________________________..t____.___.__________-__.- 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 regulations of the San Joaquin Locate Health District. , (Signed) ` ' ---------- ---------------------------------------------------------------------------------------- --------(Owner and/or Contractor) 11 \By:--•-----------••-----•---••-------•-------------i--------•--- ---------- ---------- -----------------------;.------------ ----Tale (Pl of plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). if I� FOR DEPARTMENT USE ONLY � - APPLICATION ACCEPTED BY _ ------------------------------------------------ DATE- REVIEWED BY ------------------------ ----- --- —- DATE - !' - - ----- - BUILDING PERMIT ISSUED------------------ ------------ DATE----------------------- AI rations and/ recommendations- ----- ------------ ---------------------------------------------------------------•--•-•--------------------------- 4 _ -------- ---------- •---------- -------•-- �f�. --- ------- ------------- ---------------------------------------------------------- -------------------- --- ----------------- ---------------------------- -------------------------- FINAL INSPECTION BY----------- -- ---- _ - --------- ------- Date------ - ------- ---------- - ---- ------ ----------- --------- •---- ' SAN JOAQ IN,LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 8r4 North "C" Street, Lodi, California Mantecae,Califoniia Tracy, California ES-9-2M Revised 1.57 F.P.CO. '