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(� LI-1 t APPLICATION FOR SANITATION PERMIT Permit No. (Complete 1n Duplicate) I dr7 / 1 l pate Issued ____ f--V 7_. 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 Cou t Ordinance No. 549.. r 7 WJ Fr d '9 � - /105' JOB ADDRESS AND LOCATION----r�r ------------------ ------------ -V ---------------------------------------------------------------------------------- Owner's Name-- ------ -------- F-------------------------------------- ------ Phone------------------------------------ Address-. ' ------ --- - - ---------- - --------------- - ---------------------------------- Contractor's Name--------------------------------' -- ---- --------------------------------- Phone----------------------------- f Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ___ ber of bedrooms __,I—Number of baths ,�____ Lo# size - _i________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table &Arft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � Septic T Distance from nearest well-----Distance from foundation_ � _ _1_ __ -___-Material ____�_�_ ______J I r No. of compartments__---------------- ---.2C_ - .__.Liquid depth---- -_ " _ Capacity...--DisposalField: Distance from near-well_________________Disfaance from foundation-----1-0_-._._.Distance to nearest lot line___`___________-_ ��------------Width of trench------04,14`-f Number of iines___f _____ --_._Len Length of each line___=: __ ___ 11 Type of filter material_ � d1 Depth of filter material______ `r___Total -length______OPP ---------------------•--•- See�pa,g/e � Distance fo nearest well ------ '____Distance fr foundation----- a to nearest lot line_�4'�___ U Number of pits.----/:------- ____Lining material___ _ Size: piameter___- s Depth-------49__'______________ , Cesspool: Distance from nearest well--------:Of:_____Distance from foundation--------------------Lining material-------------------------------------- - ❑ Size: Diameter-----------------------,-------;-Depth_---------------------------------------------------Liquid Capacity----------------------------gals. -. Privy: Distance from nearest well_______________, -------- -------.----------Distance from nearest building _____________________.____._- ❑ Distance to nearest lot line-------------- *-------------------------------1--------------------------- - --- -- --------------------------------------------- Remodeling and/or repairing (describe)--------------- ✓--- __-- _ rf __._----------------.___-- !!! ----------------------------- ------------•------•-----•-----•-------•----•-----------------•------------•-------------------•----------•--------------•----•------•--•----------------------------------------------------------------------------------- f� --------------------------------------------------------------------------------------------•---------------------------------------•--------------------------------------------------------------------------------------- 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. • Si ned _ { 9 )-------••---------------- --- --- - - ------ -- - ------------------------- ---- - - - - - ------------{96r Contractor) ------ ------------- ---------- - sY ..�— - (Title)----- --------------------------------------------- - - '-- (Plot plan, showing size of lot, location of sy m in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------- --------- `------------------ ---------------------------------------- DATE-------- ----------------------- REVIEWED BY-------•----------=------------------------------------------------------------- --------------------------------------------- DATE---•-------------------------- -----------------•--•--- BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations:____-________.__-__ __ I Rs - -- - ----------------------------------- •-------------------- r- - - -_a.- - -------------------------------------------------------------------------------- -------------------------- --------------------------------------------------------------------------------------------------- ---------------- ------------------CrfWQJJF_s------ ------ N D�_c T � �°r - FINAL INSPEC N BY Date--------1C .�7.` Y SAN JOAQUIN LOCAL;-HEALTH DISTRICT 130 South American Streef 300 West OakZfree} � i . 132,Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca,%,California Tracy, California ES-4-2M Revised 1-57 F.P,CO.