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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) y 04 Y Date Issued ---"l_f-- I_ 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 JOB ADDRESS AND LOCAT ON_______-_ _ _ ---- -_ ,v Owner's �Name____ _ - 1� ;d 3 ----------- --------- Phone--------- ---------- Address----------------- A -�j� •�____ - _________ L______________fs Contractor's Name____________ -- - - ------ Phone------------------------- Installation will serve: Residence Apartment-House--�]T_-Co mmercials _ - Trailer Court �_ ❑ Other, ❑ Number of living units: _/___ Number of bedrooms _S_ Number of baths ,'.._ Lot size _ -y J ote ----------------------- Water Supply: Public system ❑ Community system R��rivate ❑ Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam,❑ C1ay,Loam ❑ Clay [] 'Adobe I?;-Hardpan ❑ Previous Application Made: Yes ❑ No `New Construct.ion:._Yes- o� FHA/VA: Yes ®�o ❑ . k TYPE OF INSTALLATION AND SPECIFICATIONS; ""' ! (No septic tank or'cesspool permitted if public sewer is available within '200 feet.) •� Septic Ta Distance from nearestwecl�l_________________Distance from foundation____ __ J No. of compartments-----a4-- - -- ----Size_ _ / ---- Liquid depth----- .� :Capacity �� Disposal !d: Distance from nears well_7!t'-__ Distance-from-foundation'./-p___:_:___Distance to nearest lot line____________ Number of lines_____ _________ _________________ Length of each line f� --- _�v_Y�: dfh offrench- Type of filter material./�fP6��_"Depth of filter material____ d��!_______Total length17 ___-_ ^ ---11_ - ' ff - ---------------- 0 Seep Pit: Distance to nearest well_____________________ Distance from foundation-------------------- nearest lot line _______._._______ �f Number of pits---_---------_---`_-__Lining material-------------- ______Size: Diameter_____--_ r ': Depth---------------------------- --- \� Cesspool: Distance from nearest well-----------------Distance from foundation-------------------.Lining'material-------------------- _ �1 ❑ Stze: Diameter-------------------------------------Dept h---------------------------------------------------LiquidiCapacify------------------------ -gals. Privy: Distance from nearest weiL_______________.._ ___________Distance from nearest building ❑ Distance to nearest lot fine- ----.__-__------------------ -----------------------,----------------------------------------------------------------------------------- Remodeling and/or repairing'(describe): - - �1 Aa -- ____________________________________________________________________________________________________________________________________________________________________________________-_.____________--___________--_x -- -_ ' ' ' __ ------------------------------------------------------------- .. ___-._ _ _.. _ ___________________.___________.______________-___________._____________-__________________________an_---------------..__------___-_ I hereby certify that I have prepared this application and that the work will be done in accordance with SJoaquin County ordinances, State laws, a d rules and regulations of the San Joaquin Local Health District, (5i ned ' 9 )---- ------- ----- ----------------{ or Contractor) By:------------------------- --------------- -------------- --• ------- --------------(Title)_ ;A�d K- --------------- (Plot plan, showing size of lot, to on-of system in relation,to wells,_buildings, etc„ can be placed on reverse side). --------------------- FOR DEPARTMENT USE ONLY I APPLICATION ACCEPTED -- -- BY______-__________ REVIEWED _- ---- - ---------------------------------------------------------- DATE------ -------- BUILDING , Bi1LDING PERMIT ISSUED----------------------- - - - -------------- ---------------------------------------------- DATE----------� -----------•---- ----------------------------------------------------------------------- DATE_------------------------ Alterations and/or recommendations: ---------------------------- ------- 2-Y --------- C ff �_ ' -------------------------------------------- �D _, vl-s�F_P ��R� 1N��_A�f_�� t��tl7� Lll�1�� off, ------------------------------------- ---------------------------- ----------------------------------------------- -- R.o � saR- --------- FINAL )NSP ----K-- ----U�' / Date.- / - SAN JOAQUIN LOCAL HEALTH DISTRICT * 130 South American Street 300 West Oak Street, � .1-1 132 Sycarnore�Stree.� � 814 North "C" Street C Stockton, California Lodi, Galifoinie'L� �� ~�.y Man+e'ca, California\ Tracy, California ` E5-9-2M . Revised 1.57 F.P.CO. -