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APPLICATION 'FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the ww'k rhereiinLestrilbej. This application is made in compliance with County Ordinance No. 549. .......... JOB ADDRESS AND LOW10ti. ---- --- V # . .... ......... ............................. Owner's Name ----------------- -------------------- Phone ....................... ---- - ----- 2�_ --------- Contractor's Name__ ---•-----•------ V4.1f-t4_4" . .............. ........................................... Phone--------- ...................... Installation will serve: Residence eApart)r,ent House 0 C'mmercial 0 Trailer Court 0 Motel 0 Other 0 Number of, living units: Number pf bedrooms _3--- Number of baths 1_--- Lot size ... 1.Q..._,_ -1 ............................ Water Supply: Public system E] Communily system 171 Privite ffo"Depth to Water Table ........ ft. Character of soil to a depth of 3 feet: Sand Sindy Loam [-] Clay Loam 171 Clay [] Adobe E] Hardpan ❑ Previous Application Made: Yes E] No E]. New Constructiork, Yes [] No E] FHA/VA: Yes F] No n TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank fpr' cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest vAeIl__j/R_4_.1 .... Distance frorp foun,;l Material ption.-69 .......... ... ........ ................. Noof compartments ----- _2 --------- ----- Size.101, Liquid depth ---- ------- Capacity ... Disposal Field: Dio—rice from nearest v 11 3' 00 Distance from founclafion..;� je ----------- ,Distance to nearest lot Ruln lines .......... 41f ----- - -- e .... A.Y Number of 'Length of each lin ... .... .......... ...... K "lVdio' Width of french... Typ4 of filter material .... Depth of filter material --- /_ if - — ---------- Total length .... ......... ....... Seepage Pit: Distance to nearest well ---------_---------- Distance from foundation ..................... Distance to nearest lot line__.: _...._... ElNumber of pits------------ -- ------ Lining material_____- .. ...---.----Size: Diameter__----_-----_---------- Depth- _ ........------__ -----„-- Cesspool: Distayice from nearest well_____ ____...Distance from foundation.__::_ :--_.-._-. Lining material._.._.-_.._. - 0 1 Size: Diameter- -- -- ------ - ---- I -------------Depth_..-------------- ------ Liquid Capacity ............................ gals. Privy: Distance from nearest well-_ . ...... * --_..__--Distance from nearest building_:: _____-__ -------------------- El Distance to nearest lot line ---------------------------------- J ---------------------- ......... ------------------- ......................... ---------- Remodefing and(describe)____.................................................................... ............ .......... , /or repairing ------ ----------------------------- ..................................................................................................................................... ..................... ----------- .................................... .................. ------------------------------------------------------------------------------------------------ .................................................................................................. ............. ............. ------- --------------------------------- t------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify Apt I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sta7f lawfsftnd r le, and r ulations of the San Joaquin Local Health District. -1 (Signed) ............ 0- 1 By: ........................... (Plot plan, showing size 01 ------------------- --------- --------------------------------------------------- ---(.Owner and/or Contractor) - ------------------------ --------------------------------- (rifle) . .......................... ----------------------------------- ,rola4im to wells) buildings, etc., can be placed on reverse side). APPLICATION ACCEPTED BY_1_AV__,_A ---------- L'.”, DATE ....... ....................... REVIEWEDBY ------------------------------------------------------- .................. __ ----------------------- ....................... DATE ....... ................................................... BUILDINGPERMIT ISSUED -------------------------------------------------------------- .............................. DATE-------•-- -•- ........... ........................ Alterations and/or recommendations: ------------------------------------------------------------- .---------.-•--------------------••-----------..-._....- I ........ ............... .......... ------------------------------------------------ 7 ------------------------- ------------------ ------------------------ ........................ ....................................................................... ........... I ---------------------------------- .............. ----------------------------------- ............................................................................................................................. ............................................................................... ------------------------------------ ----------------------------------- ** ------------- * ........................................ .......... --------- ---------------- -----......................... ------------------------------------- ....................................... .................................................. 0 Gr FINAL INSPECTION BY%. ----- ------------- Date----It//_5 ............................. --------------- ----- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North 'V' Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2 M Revisea 1.57 F.P-CO.