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APPLICATION..FOR SANITATION PERMIT Permit No. — (Complete in Duplicate) Date Issued ___________ ___4 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. 549lqzq . ' i ��' JOB ADDRESS AND LOCATIO i{ '1'u-'�_--D� ------------------)---------------------------------------------------------------- Owner's Nam ---- .! -------------------------------------------- -- Phone------------------------------------ Address -----t------------- ' -- ----- ----- :; Contractor's Name--- - U' ---------------. Phone___-------------------------- Installation will serve: Residence A rtment House ❑ Commercials Trailer Court ❑ Motel ❑ Other ❑ 1 � , . 2 ,�,0 Number of living units: __ _--_ umber of bedrooms __±3_ Nof'b the 4-__ Lot size �_Q.fl___:.--X..�-7�_-------------------- m __ Water Supply.- 'Public system ❑I�,Community..syste�❑ Pri;vate.[ D�th to Water Table _"�.____ ft� i ' ! # Character of soil to a depth of.3 feet:r Sand Gravel ❑ nd L• m Clay Loam ❑ Clay ❑ ' Adobe v Hardpan ❑ ? Previous Application Made: Yes ❑ No. ' New Construcfiion: Yes �o ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPEC IFiCATIONS: (No septic tank or'cesspool perm;+ted if public sewer is available within 200 feet t f f Mat i I Se fit nk: Distance from•nearesi well-----/ -.__Distan fro ot�und n_ __ p e ,. ��` - No.'of.compartments ____tea __-____ ___Size_ I ----- - ,---Liquid depth--------ff'------------=-Ca pa ity-_�_ Y Dispos Field: +�rD stance.from nearestiwell�l� leas#an om foundationW_�_,WDistance to nearest to line-?I_ r ^ Number of lines____________ ______ _________=Length of each line__-__-____ -- Widthof trench___________ __J ' - Type of filter maferia ._._,_-_-_--_ pth of filter material____.____- �r Total length.... A ' e a r 9 Seepe Pit: rv, Distance to nearest well _ _. _ ____ __Distant fro y4n dafion___._:_____ _..Dis#ante to nearest lot line_ _ ___..•.. . Number of i#s-.°-__*- Linin material ? ---- €ze. Diame er--__.--.3_e-----_Depth_._.__ - -- p --.--. 9 Cesspool: Distance from nearest well_______r---------Distance from foundation------------ ------Lining material______________________________________ ❑ Size: Diameter-------- ------------ -----------Depth------------------------------------------------------Liquid Capacity- -------------------------gals. Priv from rom nearest'well---------------______°_---------_____________._Distance fromnearest building--------------------------------------- ❑ !Distance to nearest lot line.__- ='= =--- _ _1 , ._._-. " -- _ ; ---- --------- ---------------- --•-----------------=-- Rempdelinand/ r re akin (describe):-- -------------------------- ---------------------------------------------•------------- --------------------•--------_. ---------- ,-•-------- I ------ -•--------------------------------- ----------------------------------------------=--- '-----------------------------------------------------------------=-----------------------;-------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with,San Joaquin County ordinances, St to laws, and rules kand regulations of the an Joaquin Local Health District. (Signed) _"-"` t '�" , ---------------------------------------------------------------- --Owner and/or Contractor) 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 APPLICATION ACCEPTED BY5- ----------.------- DATE-9A--------------------- --------------- ----------------- - ------------------------------------------ DATE.-_-1-------------------------------------------•------ REVIEWED BY------------------------------ BUILDING PERMIT ISSUED-----=---------- --------------------------------------------------------------------------------- DATE-- ----------- ----------------•------- ------------ -- ------ ----------- --- ------------ Alterato and o.r recommendations: ---------------[5.r--`----�--- - ------------ ------------ .__.__._ ------------------------------------f-------------------------- ------------------------------------------------------------------------------ ------ -------------- ---------------------------------------------------- FINAL INSPECTION--BY:..--- C ---- ------------ Date w SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California F !, ES-9-2M . Revised 1-57,F.P.CO.