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/}1�1 APPLICATION FOR SANITATION PERMIT - Permit No. ....`�.`?.s_ _. (Complete in Duplicate) Date 1.Issued Applica*ion is hereby made to the San Joaquin Local Health District for a permit to construct and instaff the work herein described. This application is made in compliancea.with County�,Ordinance No. 549. j� JOB ADDRESS AND LOCATION_._. _4_ fa-4- Owner*s Name... ._= . �t- f� -4is-�(_.!x�.rt'iE- V U Phone------------- Address ---------=- O ----------- ---------------•---------•-------------•- Contractor's ame-.. Phone --------------- Installation will serve: Residence�[ff Apartment House ❑ Commercial Trailer Court ❑ ❑ Motel ❑ : Other ❑ - Number of living units: I---- Number of bedrooms . - t Number of baths .1..... Lot size - -------------------•---------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table -------- ft. a Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe M/Hardpan ❑ + Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ _ TYPE OF INSTALLATION AND SPECIFICATIONS: i. (No septic tank or cesspool permittedif ublic sewed is available within.200 feet) Septic ank: Distance from nearest wei'lz - �Q� ------_Distar c#1 from foundPtion_.-...-._..._-.....Mateg�al � _ -- I No. of compartments---------- ---�--- Size.e-4-k- - .. _n:�---Li Liquid e th---t---- --- �- ---- Ca Capacity_ q ,d p --- P ty_ y -n,,` a . DiseF'eld: Distance from nearest well- ____.._D,stance from•foundation�/�. .Distance to nearest lot line_- - Number of lines----------` ---/_ -------- - --Length of each line-_._.._.-----�- Width of trench-- c ` Type or filter material _ _______Depth of filter material_... r�M--_._____-Total length------....---j/_14! .-- Seepage Pit: Distance to nearest well----------------------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_t------___- ❑ Size: Diameter--------------------------------------Depth---------------------------- - ------------Liquid Capacity--"l-- ------------------gals. Privy: Distance from nearest well----------- ------------------------------------ ----------- ---------_-----Distance from nearest building ❑ Distance to nearest lot line--------- ---------------------------- - ------------- ---------------------------------------------------- -- - ------------------------------- Remode ing anal/or repairing (describe): 00 -74 co /� ^ --------^ ------------------------- ---------- n -------•------------ "� ------- ------ r- ----------- ---- - -- ------------------------- - - - - - -- -- - -- - - - - f hereby certify that I have prepared this application--a ndthat the work will be done in accordance with San Joaquin County ordinances, State laws, and rules arid)regulations of the San Joaquin Local Health District. (Signed).vx_�. : __i_ k ,/ a----- ------------------- ------[Owner and/or Contractor By:------------------- - Title --------------------------------- (Plot p an, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY5?------- -"---------------- --- - ------------------------------------••--------•----------- DATE-, REVIEWEDBY --------------- -1 ----------------------- ---- ------ DATE. ------------------------- $UILDING PERMIT ISSUED ------ DATE--- - -------------------- QA --------- terations and/or recommendations:..-- ---------------------------------- ----------------- ----7 ---------------- "-"----- ----- --- -----•------------- ----------------------"----- - ------------=--------------------- --- ------------ FINAL INSPECTION ----- --------------- Date----- 1 . ---------------------------------SAN JOAQUIN 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 145446 ATWOnD M