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APPLICATION FOR SANITATION PERMIT Permit Na. _. �. ._-.... (Complete in Duplicate) Date Issued 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 LOCATIO --------4-�_—&4Q.......... ...... --ST-----.,5-�o-e%oellfA.-•----------=----------- 'T -------------------------------------- Phone------------------------------------ Owner's Name-----------1AI4-- . .............�C } Address 's;� ----------- ------ --------- Contractor's Name---- -------�- = �! °x�.- x h'x�- Phone Installation will serve: Residence Apartment House ❑ 'Commercial ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: Z---- Number of bedrooms _-2- Number-of baths __f---. Lot size ------- -� __ -1 ----------------- i, Water Supply: Public,system ❑' Community system ❑ Private K Depth to Water Tableft. Character of soil to a depth of 3 feet: Sand 0 Gravel E] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No �& l New Construction: Yes ❑ No FHA/VA: Yes ❑ No L' t TYPE OF INSTALLATION AND SPECIFICATIONS: ,(No septic tank or'cesspool permitted if public sewer is available within 200 feet.) I nk: Distance from nearest well----------------- from foundation--------------------Material---------------------- -------------------------- No. of compartments------- r--Size-------------------------------Liquid depth--------- --------------Capacity--•----------------.... * ' osal ield: Distance from nearest well' Distance from foundation-,20-.,..-----Distance,to nearest lot line - --'--_- Number of lines----------/--- --- --------------Length of each line- ��_-_-h-__-----.Width of trench._-�-F�.. - mss' ---------------------- Type of filter material-_-_jk0e16----Depth of filter material----/f--,_.........Total length----- --------------•-._------ .- Seepage Pit: Distance to nearest w�lE__�' -- - Distance fromfoundation---_ Q--....___.Dista �g to nearest lot €ine-,f.r�----_--_ Number of pits------- -----------'_-Lining material------- - -pL%�_Size: Diameter------ -_-=_--..Depth------ . ---------- --.- Cesspool: Distance from:nearest,well'-----------------Distance from foundation-_---.-.----------_.Liming material_-..-----.-.--.---_-----.-_-------.--. ❑ Size: Diameter {---------------Depth--------------------- ----`x6 k Liquid Capacity------------ gals. Privy: Distance from.nearest well-------------------------- ------------------------Distance from:nearest building--------_--------__-- _________-------- ❑ - Distance to nearest lot line_--'----- ---------------------E---------1- ------"-------- ------ ------------- n -------------------------------------------- Remodeling and/or repairing (describe):_.-_ •--------•----•-----• --- "-------- ---------------------- - ,- r ---•---- - ----------------------------------------- --------------------------------------------------•------------------------------------------------------------------------ 1 hereby certify that l have prepared this'.application and that the work will-be done in accordance with San Joaquin County ordinances, State laws d rules and regulations of the San Joaquin Local Health District. i' Si ned __-___-.-----_-- ------Owner and or Contractor _L I By:._...-•-••------------•-------------•-•- -- = ----- ---- - - ---------------(Title)----- Plot plan, showing size of lot, locatio of system in.re�o wells, buildings, etc., can be placed on reverse side). ( p g FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ) ------------------------------------------1 DATE,r---..---------------------------------------•------- REVIEWEDBY------ ------- - - -------------------------%----------- DATE-- --•--------•------------------•----------•--- - ; BUILDINGPERMIT ISSUED---------- - -------------------------------- --------- Q------ --• DATE.------------------------------------------------------ Alterrations and/or recommend ations--------- --------------------------------------- k-------'------------------------------ ----------•-•-------------•----------- ------------ -------------------------------- ------�-4--T---- ----- ter" r�..r-. ! te r - t =-g--- --------------•--- =-------------------------- - -�f- � �' ---. � c_ ,/�2e'�/�" a c. ------------ ` � ,�, FINAL INSPECTION-BY: Datey 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 Revised 1.57 F.P CO. <,r