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VP\4 APPLICATION FOR SANITATION PERMIT Permit No. ._. _�- — (Complete in Duplicate, l ? Date issued --•�'~-f--�/• Application is hereby made to the San Joaquin Local Health District fora permit to construct and install the work hefein'described. This application is made in compliance with Cou ty Ordinance No 549: =" JOB ADDRESS ND OCATION_ _... ►'°---'''�- Owner's Nam = Phone ` Address-------- . - Y ........... I Contractor's Name-- ...... ....... •-•--- .................... ...... Phone.._..... ..% ......... ...... .-._.._... __...... .i......._..... x••--_..... Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer CoWjQ Mote, ❑ Other Number of living units: _I.,_ umber of bedrooms_.. Number of baths L•o�0$19F�0--- .f, Water Supply: Public system Community system ❑ Private-❑ Depth to Water Table ........ ft. ' Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy LoanI Clay Loam❑ Clay❑ Adobe Hardpan Previous Application Made: Yes ❑ No New Construction: Yes Rf No ❑ FHA/VA: Yes ❑, No: TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or°wc6sspool p*Mitted 1p ublic s- or wavailable within 200 feet.) Septic nk: Distance from nearest well ista cY�omf f`ountion.�f/ 4ater aI . No. of compartments. Size. ....Liquid eptb -._-_..•Capacity. p Dispos 1 Field: Distance from nearest well / c�• }i Distance from foundation_.__ .Distance to nearest lot line r� [y�f Number of lines ___..._.-�' ............ ' Length of each line___. ___ � Width of trench ,� .. Type of filter materi ._ _.-_-.Depth of filter material -, --------Total length... ...._... . _- D........... Seepage Pit Distance to nearest well----------------------Distance from foundation....................Distance to nearest lot line -- -------- ❑ Number of pits ---.- ____.Lining material- --------- --------Size: Diameter..- _-._.Depth . _ `. Cesspool Distance from nearest well -.:.._ Distance from foundation-_._- _-.---.•---Liningmat, ❑ Size: Diameter Depth -------. --------Liquid Capacity .......gals. Privy: Distance from nearett well .__._------------------Distance from nearest building _. ..: Distan6e to nearest lot line--. • ----- N Remodeling and/or repairing (describe): - -------- -----•-- -----.............- ------•--•- ----------------------------------------------------------------------------------- -----•-- ------ ••-- •-••---• •------- ..---- ...•••. ------•• ------. ------. ---- - --•- ---•- --....,------I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin-4,;�ounty ordinances, State laws .and rules and regulations of the San Joaquin Local Health 011st ct. - . ----- y ------------------------------------4 (Signed)---------E.:�= - ^'�'-� -, � ----•-•-- -•---•--- --•---(Own®r and/or Contractor) By:........................................................................................................ (Title). •-, -- -•------ - - (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 `Q PPLICATION ACCEPTED BY -- --- - - - ------ DAT ----- ----- --- REVIEWED BY. _.. DATE qA. BUILDING PERMIT ISSUED. .._. .-_ _______ ATE --------- Alterations an /or re endations - r�,�/)� F / • .r y G ..... FINAL INSPECTION BY:..A,-- 2 .._...--- Date--------- SAN JOAQUIN LOCAL HEALTH DISTRICT "0 South American Street 309 West Oak Street 133 Sycamore Street 814 North "C" Street ' Stockton, California Lodi, California Manteca, California Tracy, California 4 ES-9-2M Revised 1.57 F.P.CO. c"