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APPLICATION FOR SANITATION PERMIT Permit No. a.. Y'2 ` (Complete in Duplicate)t I� y/�- Date Issued ............eK 1--...� Application is hereby made to the San Joaquin Local Health Districts a permit to construct and install the work herein described. This application is made in compliance with County 0 clinanc No. 349. JOB ADDRESS AN ATION --�=�0------- - - - -- - ---- '/ �-------------•---------•------------------------------------- Owner's Name ....... . --• -------------------------------------------------------------------- -- ------ Phone ---... • ----- Address.......... Rl�-� ••----------I---- .................... .. Contractor's Name ............................................... � - ----• ----------------------- ---- •----• Phone.--------- Installation will serve: Residence Apartment House E] Commercial E] Trailer Court ❑ Motel ❑ Other F]Number of living units: _.. ``Number of bedrooms A--2---Number of baths --- ./_ Lot size ------------------------------------------- ............. Water Supply: Public system ?� Community system TSPrivate E]Depth to Water Table V_ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe K Hardpan Previous Application Made: Yes ❑ No 9C New Construction : Yes ❑ No K FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or` cesspool permitted if public sewer is available within 200 feet is ank: Distance from nearest wJ `Oi rstance from foundation .... .. ..........Material ------------------------------------------------- No. ..___________________ __...._._.____._.._...No. of compartments---------------------Size.------------------------------Liquid depth-_-------------------_-- Capacity Disposal Field: Distance from nearest welle.1Distance from foundation ARDistance to nearest lot line ....... �� Number of lines._...-_ �__�__�_-�- Length of each line:____ ,S' r t� Width of trench .�_ �� ............. Type of filter material..•31..A"_Depth of filter material.._._,l - __- Total length---------- `. `.................. Seepage Pit: Distance to nearest well �h _ _Distant om Ifo dation... �?r..... istance to nearest lot line.-�_..... ? - -- [ Number of pits ___{-_________,__ Lining material__ ___ -Size. Diameter -._3..!_ ----------- Depth ----- P?S—__________________ Cesspool: DisAoce from nearest well Distance from foundation ___ .Lining material .............. ❑ Size: biar`neter------------------------------- --- ---Depth--- ---- --------------------------------- ---_ Liquid Capacity- ------- ------•--------gals. Privy: Distance fro'mhnearest well ------------------------------------------------- Distance from nearest building ------------------------------------------ Distance _-_ ________ ______________________Distance to nearo ]of line'--- - - - ----------- - Remodeling and/or rep6irin4(describe): = - --------------- -- ................... ----------- # ----- ------------------------- ....................................................................................................... 4 .... 7 ......................... f .............................. --------------------------- -------------------------------------------- . -- -- ..... ............•-•-- r ,. ------ I hereby certify that I .lyeve prepared this application and that the work ,'will be 4one in accordance with San Joaquin County ordinances, State laws, and ru and regulations of a San Joaquin Local Health Dlst.P. (Signed)---------------•----- . •-----... -----1� ---------- By: __. Owner and/or Contractor B' - ---------- -- (rifle). ----------------------------- ------------ (Plot plan, showing size of lot cation of system in ,relai i n to wells, buildings, etc., can be placed on reverse side). FOR ARTMENT USE ONLY APPLICATION ACC PTED BY------- -- -- --- ------ [SATE .------• • r'�j REVIEWED BY.; DATE j BUILDING PERMIT I UED ------------------------------------ --------------- ----- •--------------------- DATE-------- ,/ ---- ----- Alterations and/or recommendations: - -------------------------- - •---=------ ------ ------ ............ ------------------------------------------------------- -----.-- ? `l - - - - � -- ... ... ----• ....... -•--- - --- --------- ---- -------_----.__. FINAL INSPECTION BY:-_� "---•--}_-- - ----- Date ------ ! / � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California Lodi, California Manteca, California ES -9-2M Reviseci 1.57 F.P.CO- 814 North "C" Street Tracy, California I