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G�77 \� APPLICATION FOR SANITATION PERMIT Permit No. ...............,h,..... (Complete in Duplicate) Date Issued A plication 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 LOCA ION--- s------- - ------------------------------------........... ..,........................ Owner's Name--------1 �/' _ Phone Address--------------------- ---•--•• • ......... . ---------- _---- ------ 17 _. Phone. t - -------- ------_ Contractors Name--•----------�/��'.c�se�--------- -------- ---� - ---------�.'_-� 'C��..`��"�I''� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ > le Number of living units: __f.__ Number of bedrooms -%7-. Number of baths *.._. Lot size ---Z ee- X.,1'.ZcV............... Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table `•ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe&--Hardpan �] Previous Application Made: Yes ❑ No 9�New Construction: Yes U--<o ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) / �r Septic Tank: Distance from nearest well_) Distanceff rom foundation_14P..........M3a eaL Cr_ r ._..___. _._. city_No. of compartments____ ___ ____Size."_.'_�0__Liquid dpth__'� ---------. Capa ,... Disposal Field: Distance from nearest well N $istance from foundatio 14 ........Distance to nearest of line....5_�..... Ile Number of lines________________ ___ ength of each line------- ------Width of trench _.__ __ Type of filter material, _ ----- epth of filter material---/�---- • -Total length. i Jr Seepage Pit: Distance to nearest well ---_I' C/Distance from fou ation-_,�_P_........D��7,P to nearest lot in .s .f � Number of pits ------------Lining material/_ Size: Diameter. Depth - P..... ---•- Cesspool: Distance from nearest well-----------------Distance from foundation__.................Lining material---------_------------ 1-1 _--_-_...__ _- ❑ Size: -Diameter--------------------------------------Depth............................-----------------------Liquid Capacity --.--- •. --.gals. Privy: Distance from nearest well -------------------------------------------Distance from nearest building-----.___::•--_•___.___-___-._-.-______-. ❑ Distance to nearest lot line----- - ------------------------------ -------- ----------------- -----•--- (� Remodeling and/or repairing (describe)--------4T�' ' - --- • -- ----------------------•-----•--------------------------------------------------------•.............................----•----------•----------•••• -- ---•----•--••-•-- ------. -•••---------•--------••- ----- 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 ? � 'J9wrte? "'► Contractor) B _-------------------••---•-••--•-•-•-• •----- -- -------------------------------------------------(Ti+le)-------- -- ------- ------- (Plot plan, showing size of lot, to ionof system in relation to wells, buildings, etc., can be placed on reverse e). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-- ---------------- ----- DATE---------- REVIEWEDBY---------_--------------------------------------------- --------- ---------- -- - --------------. DATE---------- _.._ . BUILDING PERMIT ISSUED-•--•_--_-__•---_______•__________I ---------------------------------------------------------------- DATE..............................------------------------••----• Alterationsand/or reco mendations------------------------------------------•----------•••••-•---•-•-•--••--------••-•---------•-•---••---•-•-•-•--.....•----•••••••----•••-••.........--•--•---- t �.. ------------- - ---------------•----------------------------------------T---------------------------------------- .................................. ---••---- ••--•----•---• ••. ---------------------------_... --------- --------- -------- --- - ----- --_-----------_*................... FINAL INSPECTION BY:----- -------------------------------------- Date---�2 -- -_-------------C f 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.