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V' w APPLICATION FOR SANITATION PERMIT �9� Permit No. ....... / LI-21 (Complete in Duplicate) Date Issued /Application is hereby made to the San Joaquin Local Health District for a permit tKc/strucf d install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCATION 1 -- ------ . -----•---° � Owner's Name Y.f./f'0 �. -- - - --- - --- ---------- ---&- �a Phone ..................F.. _...•-- Address--......*,R....Vi �----------- --•-•-- Contractor's Name ---.& ---••- ... Phone,....... ......-• -----•-- Installation will serve: Residence<*-I`partmentHouse ❑ Commercial ❑ Trailer Court ❑ -Motel ❑ Other ❑ Number of living units: _f._ Number of bedrooms _♦ Number of baths ---/. Lot size _ _, - Water Supply: 'Public system ❑ Community system ❑ Private k'15epth to Water Table i�$' ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam [] Clay Q Adobeardpan-❑ Previous Application Made: Yes ❑ No ❑ New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest 1 Distan rom f undation._._- M tgria� e No of compartments---A.: ______ f Size -.: Liquid depth --------Capacity �e l 7r / Disposal Field: Distance from Weare well. .Distance from found t' n ../0 Distance to nearest lot line �� Number of lines.-..-± _ __ ___________ Length of each line -_.- - Width of trench...1� _ i) Type of filter material/y_AFsV_- o.Depth of filter material---_-/__� ------Total length------ / . Seepage Pit: Distance to nearest well_____________________Distance from foundation....................Distance to nearest lot lime................. Q Number of pits ------------------Lining material_------ ----------.Size: Diameter........................Dep th-------------- ` ._.... Cesspool: Distance from nearest well•___-_-_•____•_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 •=•- . •--• ._....a_ ----.-_ ---------------------- -------- ------ - Remodeling and/or repairing (describe)------- - - - ......... --•••. ••. .......... ---------------------- ------- -------------------- -------- ------------------------------- ------- ............................................................................................... I hereby certify that I have prepared this application and that the work will be done in accordance with Sao-Joaquin County f ordinances, State laws, an rules and re uI tions the San Joaqui Local Health Distract. ` v (Signed)--•----•---- �..a _- --- -----• -- -••----- ----- --------=(O�rtre�+„'�Ff ter-Contractor)-------------------- . ..� (Plot plan, showing size of lot, cation of system in relation to wells,buildings, etc., can be placed on raver side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY-•----- ------- - ---- . - ------------ DACE `. ,.. / ... REVIEWED-BY ----•-. - ------ DATE • �_'.�( BUILDING PERMIT;ISSUED-_ DATE • ... --------- ------------ terations and/or recommendations - ....•!... ................................... . ...__ ----- F---- ------------------------------------------------------- ------- ------- ------ •...... .-------------------- ------.- ............ ........ . FINAL-INSPECTION BY:------- ---- -- ----------------- Date--------- '` . 9�AAN v JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wast 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.