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o� t-II y - 1 APPLICATION FOR SANITATION PERMIT Permit No. _..1 .;2�_L S 1 (Complete in Duplicate) Date Issued .... �. Y 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 ADDRIESS AND ..�'.;` ..,. Owner's Name-----7.7jAd AMS-- - - - - ------ - _----------- Phone ... 2 .... Address_.__ Q= Q X..._. �? :--:'---, fzF,- t'_/fi�._ .e !1 _ �,e �f__�'--------- ------- Contractor's Name------- `- —----- ?_' • % �`— tz_�1� — 'rs��`''----------- -------_ Phone _. vez Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: /---_ Number of bedrooms.. Number of baths ___l. Lot size ..12'a....e?! .......................... Water Supply: Public system ❑ Community system ❑ Private1WDepth to Water Table 7Q ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe❑ Hardpan Ej Previous Application Made: Yes ❑ No x New Construction: Yes ❑ No 1�r FHA/VA: Yes ❑ N04 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance e from nearest well___. ...Distance from�found��ion-__ „� ___..__.Material�r ,� .Q . [� No. o compartments---- ---Size...... __Liquid depth__----S Disp sal Field: Distance from nearest well —ff Distance from foundation._________Distance to nearest Jot line-,/ Number of lines------- ____-__Length of each line___d2W__-�.�Q._.'...Width .of trench ,• t >f Type of filter material__--__,F!0.6- __.Depth of filter material_-_ _Total length.....-�.......................... Seepage Pit: Distance to nearest well __________________Distance from foundation....................Distance to nearest lot line................. w ❑ Number of pits.---------------------Lining material-----------------------Size: Diameter........................Depth Cesspool: Distance from nearest well-------------------Distance from foundation--------------------Lining material.. _...._.—------------------— x ❑ Size: Diameter---------------------------------------Depth----------------------------- ---------------------Liquid Capacity gals Privy: Distance from nearest well. _-__-.-_________ _____ ____ __ _Distance from nearest building_----- _------------------......El Distance to nearest lot line------ =---- ----- ----- --------------------------------- ----- - ------ •-- ...... --------•• Remodeling and/or repairing (describe) ----------- ------------------------------------------- --•-------------------------....................................... 00 •--- ---------------••---•-------- ---------•-----------------••--•---•- •..•.----_---------------------- ----------------------•---------- --•-- -------------------------------------------------------------•------•---------------------------------------•------------•--------••--•-----•--•-------------------•----•---•------•---..........--•-...._-••--------------- I hereby certify that I ha prepared thi plication and that the work will be done in accordance with San Joaquin County ordinances, State laws, and sad reg io of the San Joaquin Local Health District. (Signed)----------- --- '' t '"_- Owner and/or Contractor) By:................... --------------------------- -------'-- (Title) .R. ------ (Plot plan, showing size of lot, location of !ryste6 in relation to wells, build s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -------- ----- -:...........--- ._.__------ DATE67 REVIEWED BY -- - -- DATE ' , BUILDING PERMIT ISSUED — -------------- ............ DATE------ ---- -•--- Alterations and/or recommendations------------------- ---------- --------- -------------•-•--•-----------------------......._.................... ----•------------------------------------------------------------------------------------------------------•-------•-----------------•---------........................................... --•---------- -------------------------------•-------------------- -- --------- ------ ----------•.._:......------• - FINAL INSPECTION BY__________ ___ _ ----- -_------.___-- Date-...-. -.- -- -_._ 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.