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r� APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) _ �/y� Date Issued . �___._.y._ FO Application is hereby made to the San Joaquin Local Health District fora permit to o truct and instal work herein a rib . This application is made in,.comppli_ance.with County Ordinance No. 549. ' p . Y JOB ADDRES 9 L CATION.AA__-_ --- ,--- ----`-`'I- -�_c--l/E/ 't ►�`-- ------1-- 9a I�.... - ,o --------------------- Owner's Name • ------------------------ - -------- ------- - Q - Address-- Q R w -------------- Phone.---------------...__ Contractor's Name --- -- -•-------------------•-•------------ Installation will serve: Residence ►Apartment House E] Commercial ❑ Trailer Court ❑ Iv4gtel ❑f, Other ❑ Number of-living units: __ -__ Number of bedrooms __'_. Number of baths __1____ Lot size S__y-f-_X-'`�`-° -----•- Water Supply: Public system [I Community system ❑ Private L F""Depth to Water Table '"---- ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy loam Clay Loam lay ❑ Adobe E] Hardpan ❑ No New Construction: Yes. No ❑ FHA/VA: Yes F] No E]Previous Application Made: Yes ❑ TYPE-OF INSTALLATION AND SPECIFICATIONS: (No,septic tank or'cesspool permitted if public sewer is available within 200 feet.) VV 1 Septic nk: Distance from nearest well____4- ----.-Distan/c�l fro fou tion____ __.'...-_.Maters f�bal, No. of compartments-------------�u---,-'Size---"7..x_�x __Liquid depth-- .-_---- ----------Capacity---1 �-�j----- } # __...).Distance from foundation__ _.Distance to nearest lot lin _ _�' ! Disposa Field: Distance from nearest well _ --f-•- +f Number of lines----- ---- ------ ---------- -Length of each line------__-.-- Width of trench.--:-----zt ,:�____------- Type of filter maters ----- Depth of filter materiaL______q_'r______Total length___________________ ie o Seepage Pit: Distance to nearest.well"_______-___----_=_Distance from foundation--------------------Distance to nearest lot line_________________ 1 ❑ Number of pits-._._ 1 1, __ material-----------------------Size: Diameter-----------------------.Depth--------------------------------• °p : ,. t -. i Cesspool- Distance from nearest well-------- Distance from --------------------Lining material----_____..___.__--._______.___.____. ❑ Size: Diameter___ --------------Depth ------------------= --------------------Liquid Capacity------------------------ -gals. Privy: Distance from nearest well__._y-____,__------------------------------------Distance from nearest building_--------------------------------------- ❑ {� -,—r -_ to nearest lot line T��-"'r= = ------------- Distance Remodeling and/or repairing {describe):_' ------------------------------------ ------------- -------- ------- = = = ; _______________ y.. _______________________________________________ - -------__---------____________________________________________________________________________________________ I hereby certify that I have 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. f� ------------------------------------••------------- Contractor) � . (Signed)__`! (Ower and/or n { By----- --------------------- --------=-----------'------- --,------------------------------------- -{Title)----- -----------T--------------------------------------- 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 APPLICATIONACCEPTED B - ----------- ---------------------------------- -------------------------------------- DATE�..r.. REVIEWED BY €; --- ---- -- --------- DATE-- ;.------------------•-------••---------------------- BUILDING PERMIT ISSUED----------- --- DAT) ��c-- Alter ion4sd / r re o .m dati __ ._:_______ .._ ----------•-------- ----------------------------------------------------------------------------------------------------- Date__. .4 r _^ /,7-------- ------------------------------ ---------- FINAL INSPECTION BY:. _- � '' n SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street [32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-4-2M Revised 1.57 F.P.CO. i