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APPLICATION FOR SANITATION PERMIT Permit No. _./d_T_ . _ (Complete in Duplicate),, f/ Date Issued Application is hereby made to the San Joaquin Local Health District for a permit[to co s�t�Fuct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AN,,LOCAL I N-----: F __.,_ / ---------• ----------------------------------------------------- --------------------------------------- Owner's Name---- `1 ' Phone 6 '- ----------- --------- ---- ------- dli r. ov Address---------------- # ------------ yy f/ ---....._..- •-------�-- -----------t •_--__--_----___--_--_------_---------_-_-__• Contractor's Name w ------------- ------4.. -----=�F.*---- /Phone-------------------------•--------- Installation will serve: ResideiceApartment House ❑ Con4ercial ❑ Trail erCount 'Obtel ❑ Other El !f Number of living units: -_/ -- Number of bedrooms _- .*'Number of baths .fes Lot �________________________ - Water Supply: Public systemCommunity system ❑ 1P�nvate 2�epth to Water Table Iv- ft° Character of soil to a depth df 3rf�e�: Sand ❑ Grave ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe lardpan ❑ Previous Application Made es ❑ No Ej-'New/Construction: Yes ❑ No EK--FHA/VA: Yes ❑ No [�4 - TYPE OF INSTALLATION 'Al D fSPECIFIdATI.CrNS: (No septic tank or cess*oo)ypermifted4f public sewer is available within 200 feet.) �4L p No. of cpartments`_ -�----Sii_--- ------" Liquid dap Material------------------------------- 411 ----------------- S e ti Tank: Distance h m nearest well---- _-A--I-Distance from foundation--.----------- h Capauty-----------------_---. , ispo I'Field: Distance from n eare�st well- .-----Distance from Fun-J3—No --------------------Distance to nearest lot line-._--_-------__-. ��- «`t r Yr Number of lines Length of each line '----- Width of trench ----- ----------- Type of fillFer f material------- -- - Depth of filter material----------------------Total length------------------------------_----------Seepage Pit: Distance tJr nwest well-- �_ { n Distance frolor'i tione-- r/ Distance-.-.. to nearest lot line _-_---- [P" Number 011 pi$s"---/----------- fining material-�-,�, 4 ize: Diameter__-?Y__ _------Depth------�ea4-_---'*----------- p - l------------- ---Distance from foundation ------------------ Linin-g--material------------------------------------_. -------- Cesspool: Size:Dia'i'eter-------------------------------------- neares- well-- -Depth-------------- --- ------------------Liquid Capacity----------------------- ----gals. Q Privy: Distance f�om nearest well-------------- # -- y qh ---------�- --DistpnA from nearest building----------------------- �] ------------------ ❑ Distance to nearest lot line---------------=------------ g / P 9 r i(descriL�e): ------------ Remodeling and/or re ainn F I I r --------------------- --------------------------------------- -----k-------------------------•----------- - - ----- -------------------------- - ----------------------- -------------------------------------------•----- � --------------•-----_--I-•-•---I----------------------------------- ----------------------------------- a 10 ---------------------- ---------------------------------------------------------•------------------------------------------------ ----------------------------------------------- ------------- 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. _ (Signed) { �"hd Contractor)BY -----------I-------------------- --------� ----------------------------------- Title----- r/ /�/. or o or 1� (Plot plan, showing size of lodlocation of stem in relation to wells, buildings, etc., can be placed on reverse side). �f FOR DEPARTMENT USE ONLY yip _ APPLICATION ACCEPTED B' -------- DATE- - - - REVIEWED BY------------------------- � y. DATE ----- - ---------------------------------------------------- - -- BUILDING PERMIT ISSUED___0----;...--"t------------------------------------------------------------------------------ - DATE:------ Alterations and/or recommendation----- .----___-----_ ._ ------------------------------------------ -------------------------------------------------- "---------------------------------- ---- •---------------------------------- ----------p•--------------•-------- n1, ------------------------------------------------------------------------------ ------------------------------- ------- ----------------------------------------------- --- FINAL INSPECTION BY:.-...... 'Ll- --------------------------------- Date--.-./.r -- J1 i t� SAN' JOIST AQUEN LOCAL HEALTH DISTRICT .. � . . 130 South American Street i 300 West &kh.Stred} t 132`•Sye;ampre Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 , Reviseci 1.57 F.Pi O.