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_ APPLICATION FOR SANITATION PERMIT Permit No. �/ { (Complete in Duplicate) .-•• Date Issued App 1i ion is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance o. 549,. C �. JOB ADDRESS AND L CATION---•---�-� ��- ----�'-3---------.� - �- � ` - -------��--------------------------------------------------------------- ------ Owner's Name----- - A-A74----------- -- --------------------------------- Phone----- _Z--- Address----------------- ---------- ----------•------- aD ��-----'S----4-:-----J --- -`------ �r� f.1------------------------------------- Contractor's Name-•----------------------� x'4'1 - xj ------ Phone----------------------------------- , Installation will serve: Residence�1 Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: r -__ Number of bedrooms Number of baths _ ____ Lot size __------___J--/:'_I----____________.___- l Water Supply: Public system �k Community`system ❑ Private ❑ Depth to Water Table _______ ft. } Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ rr .. ' Previous Application Made: Yes ❑ No� New Construction: Yes No ❑ PHA/VA: Yes ❑ No ❑ W TYPE OF INSTALLATION AND SPECIFICATIONS: -'J (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic�T nDistance from nearest -Dx �n ' f - Material-------------"-A---- -:- Z - ------ No of com artmets_ eluid dePthCapacity Disposal •----"---"-- ------. Field: Distance from nearest well IA Distance from foundation_;_�g__________-Distance to nearest lot.line____-_" Number of lines-----------_ ---------Length of each line________ Width of french------ _____________--------- Type of filter 'Material ___�1A-______Depth of filter material_______ ___________Total length--------1)► _ ---------------------- Seepage f___________________Seepage Pit: f. Distance to nearest well_______________._____Distance from foundation--------------------Distance to nearest lot line--------------- ._ ❑ ' ' g vk ., '.Number of,pits Lining material----------------------- Size: Diameter______________ Depth Cesspool: Y, Distance from nearest well_________________Distance from foundation--------------.____.Lining material------ Size: Diamefer------------------ ------------------Depth----------------------- Liquid Capacity jg_al,. ------------ 1 _____________Distance from nearest builcli� Privy: Distance from nearest well----------------------------------- g__________.______.___________ ❑ Distance to nearest lot line-------------------------------------------------------------------------------------------------------------------------------- Remodeling an, o re firing (describe):------ _- ,`------- ----- -- (.L -- -- ----- ---:._ ,_� - -------�-^�_ = --- - -� s 6 -- - --------- - - - --- - I hereby certify that I ha4e 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 Local Health District. (Signe ___ _ d} i �'`7 = " %f= Owner and/or Contractor) By- ----------I—.........--------------------------------------- -----------------------------------------------------(Title)---------------------------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY i. APPLICATION ACCEPTED BY---------------- '----------------------------- --------- DATE-------- -------------. r 1�= REVIEWED BY------- ------ f ---------------------------------------------------------- ---------- DATE----- BUILDING PERMIT ISSUED-------------- •----- • -----•---------------------------- DATE---------------------------------------------------------- Alterations and/or recommendations----------- -------------------- -- -- -- ------ -------------•------•-------------••-------•---------------•------------------------------ V f � � ------------- C `Z'_L`�"�- -----�----- ------------ ------ ----------- - ------ a R= -------------------- -------- ------------- ` z-3-�- ----------------------- _1 FINAL INSPECTION BY:.------- -------• Date- --------------- ----------------------- j7/A/ ------------------- - r y�` JO„pQUIN 'LOCAL H A TcHH DISTRICT - i30 Duff$ Ameriban Sn �� 0> West Oa'kp5+reef ' �lr5ycamore S+rb6+ 914 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-4-2M , Revisea 1.57 F.P.CO.