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APPLICATION FOR SANITATION PERMIT Per tit No. (Complete in Duplicate) 4 6+1; did DaNe'T Application is hereby made to the San Joaquin Local Health District for a permit to construct an install the work herein described. This IPfiapplication is made in compliance with County Ordinance No. 549. JOB ADDRESS :Ay OCATION-------- --- Q-- --- ----- ---- .. ....... Owner's Name--- - ----- ----------J_..----- ----- --------------------- Phone Y6__._;,-__711-J Address--------SA-1------- -------------I- --------------- C 5--------------------------------------------------- Contractor's Name-------------------- ----14-X--------------- ---it�-= ? -__.z--------------------------------•-----.-. Phone---------------------- Installation will serve:;?ResiWdence E] Apartment House Ej Commercial 1-1 Trailer Court El Motel [-I Other 6 0. ay Number of livAg units: -------- Number of bedrooms -------- Number of baths -------- Lot size --- --------- f Water Supply: Public system [j Community system El Private fk Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand [:] Gravel El No New I-] Sandy Loam Clay Loam E] Clay E] Adobe❑ Hardpan ❑ Construction - ,es— 91P. Previous Application Made: Yes Construction: Yjd_ No FHA/VA: Yes ❑ No 9- I . 1 0 Z_ +4 TYPE OF INSTALLATION AND SPECIFICATIONS: P_ T /- 3 V (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic TaDistance from nearest well---&0_____.Distan;c19�1_oMf usn"clation----A:9:n%_..MateriaI-------- --------- No. of compartments-_3-------------------Si�e_ -- -- ----- --- 10� V Liquid depth--___--_ Disp sal F. Distance from nearest well-6.- k .4 n =stance da 10 -7-1-6-------=stance to neares ]of 11Z;' Number of lines-----------�0_ ---Olt of each line-----4-69_-C)------------Width of trench----- _y---f- Type of filter material---- ----Depth of filter material-----IX?�-------Total Iengfh_'x-j:-.-2j ------- ll Seepage Pit: Distance to nearest well-------------- -------Distance from foundation--------------------Distance to nearft lot'line.--.---______---_ ❑ i,e----------------- 111 Number of pits----------------------Lining material--------------.--------Size: Diameter----------_-----------.Depth-------------------------------- Cesspool: epth---------- --------------------- Cesspool: Distance from nearest well-________________Distance from foundation------------------- Lining material________----___.----._------_________. ❑ aterial------------------------------------- E:1 Size: Diameter-------------------------- --------.--Depth----------------------------------------------------Liquid Capacity- - ------------------------gals. Privy: Distance from nearest well_____ _________________________Distance from nearest building____-_-_-------_________________-_-___-_. ❑ Distance uilding----------------------------------------- Distance to nearest lot line------- Re ine------- Re odeling and/,or epairing (describe):-- W.- -------- ----- -- - --- -- _e _0------------------ - ----------------- -3--- --------- - ---—------------------- ----•------------------------------------------------------------------- ----------------------------------------------- hh ---- I hereby certify fAl h.-3,. prepared this application and that the work will be done in accordance with San Joaquin County ordinances, St'a I and rules and regul�ationjy�j,--Vfh -=an Joaquin Local Health District. (Signc - ------------- - ------------------ --------- -- - -- ------- - ---- -------------------------------------------------------- (Owner and/or Contractor) 19 By:------------------------------------------------------------------------------------ ---------------------------------I-------------(Title)-- ---e,------------------------------ (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 BY-------•----------------------------------------------- - -------------------------------- DATE REVIEWED BY-------------------------------------- ------------ --- - DATE-:-:--' -V ---- - - ------------ BUILDING PERMIT ISSUED e ---- ------------------- -- ------------------ D/ --------------------------- ------------- Alterations and/or recommendation-------------------------------------------------- ------------ ------------------------------------------------------------------------------------------------ Permit-_x ead 91 I_--This,--sys _temto--accomo"te- nen-----------100-- ---------1--------------------------------------------------------I------------------------------ Addlt ional--man_w1U--necessitate--add-4 tLow,tp--the---S"tem,-------------------------------------------------------------------------------------------- -------------- --------- ---------- --- ------ -------------------------------------- --------------------------I--------------------------------------------------------------------------------------I---------------------------------------------------------------- FINAL INSPECTION BY:---------------------------------------------------------------- Date------------------ SAN 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-9-2M Reviseci 1.57 F,RCO.