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- , APPLICATION FOR SANITATION PERMIT Permit No. {Complete in Duplicate} Date Issued Application 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 No. 549. s JOB ADDRESS AND ATION.-- - g �4 ` r � ------------------------------------- p Owner's Name - Phone ------------------- ------------- Address - Address---- ------- -------- ------------------------------------------------�-------•/-------•--------- ---- I Contractor's Name ----------- ------ Phone1?`--dA----,-;-a47 Installation will serve: Residence D/partment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i Number of living units. __ __ Number of bedrooms _ Number of baths __ _____ Lot size ____� -__ -----,h-7V------------------- Water Supply: Public system a---community system ❑ Private ❑ Depth to Water Table -7--o ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam E] Clay Loam ElClay [IAdobe Ey—HardpanF-1Previous Application Made:-Yes [:] No Eg----N-ew Construction: Yes ❑ No 2j----FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: 1 (No septic tank or'cesspool permitted if ublic sewer is available within 200 feet.) _.Materl_-- _ Septic Tank: Distance from nearest we __/-� - --_Distance from foundation____--�---------- No. ----- ------ - No. of compartments__------- __________Size__ - -- ------3-Z--------Liquid depth-- -�./--,��------ -- Capacity------��- -- os'I,field. Distance from nearest well_________________Distance from foundation________________-_Distance to nearest lot line-_-_____________ Number of lines-----------------------------------Length of each line------------------------------Width of trench.--------------------. ------------- Type of filter material---------------------.---Depth of filter material-----------------------Total length------------------------------------------ a Pit: Distance to nearest well---------------------- from foundation-------------------- to nearest lot line----------------- [ j _ _ Number of pits rriaterial----------------------.Size: Diameter------ ----------------.Depth------------- q Cesspool: Distance from nearest well-------:--c------Distance from foundation---------------------Lining material _____._------------------------------ L1 __-__________-____ ----___.❑ Size: Diameter---------------------- -----------Depth----- --------------------•-----------------------Liquid Capacity---------------------------gals. {" Privy: Distance from nearest well------------------1-------------------.-----------Distance from nearest building-------------------------_---------------- i ❑ Distance to nearest lot line-----------------±----------------------------------------------------- Remodeling and/or repairing (describe):- ----- �ti _-- ----- ---- �1 --------------------------------- r ------- = DA ------ -- ------ ------ -- -- ----- � '.: ` ---------- ------------------------------------------ I hereby certify that I have prepa ed this application and that the wor will be done in accordance with San Joaquin County ordinances, St 75 , and rules and regul ions of the San Joaquin Local Health District. (Signed)------------- N ---------------------JW. caner and/or Contractor) By:--------------------------------------------------------------------- ----- {Title} 211 (Plot plan, showing size of lot, location of system in rela ion to wells, build' gs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----T- . ._ ---------------- DATE--------g77-6-- ------- - 6--4-: REVIEWEDBY----------------------------------------------------------------------------------------------------------------------------- DATE------------------ BUILDINGPERMITISSUED------------------------------------------------------------------------------------------------------ DATE Alterations and/or recommendations:-------------------------- - ------------- ----- ------------------------------------------------ I�--------lw_�LL.--------- ----------------------- ------------------------------------------------------ - --- -- -- ------------------- ------ -- -------------------------------- ------------------------------------------7------------I-------------- ------------------------------------ - ------ -------I------- ---- -- -------- ---------- --------------------------------------------------------------I------------------------------ BY FINAL INSPE :__-- ' -------- - --- Date SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 30D 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.CC1.