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APPLICATION FOR SANITATION PERMIT Permit No. _ � 11� (Complete in Duplicate) S Date Issued Application is .hereby made to the San Joaquin Local Health District fora permit to construct and install the work herein described. This application is•made in compliance with County Ordinance No. 549. JOB ADDRESS AND LO�CATION/ AX-1,—A-3 ' , __t` � ? K--- ------------------ - ------ Owner's Name------ _�_. i?lE" !_ ?.F. �- Address ----- "'"Phone----/ d----•------------------- rr 7 5'�'-d. --`�---- ` 1Contractor's Name.------_ ._, -E"`" _ •�_ `/" i, Installation will serve: Residence Apartment-House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other Number of living units: __ -__ Number of bedrooms -.a- Number of,baths _ __ Lot sizeJ?6__ -6 Water Supply Public system�❑ Community system ❑ Private, Depth to Water Table„._ ft. Character of soil to a depth of 3 feet:—San ravel ❑ Sandy Loam 5Z Clay Loam ❑ Clay ❑ Adobe ❑' Hardpan[J Previous Applicafion Made: Yes ❑ No % New Construction: Yes D( No ❑ FHA/VA: Yes ❑ No,X" TYPE OF INSTALLATION AND SPECIFICATIONS: r I (No septic tank or'cesspool permitted if public sewer.is.available within 200 feet.) Septic Tank: Distance from nearest well4 Distance from foundation _ - Materialrs.%r. '�^ ....: No. of compartments_.___ ., _ ._Size-- Z -----------Liquid de th - Ca acit ,/�� _- Disposal Field: f Distance from nearest well.`_ ____Distance from foundation'—70-------..Distance to nearest lot line-t�r ----- I Number of lines----_ ._-. ------------------Len th of each line..�d --------Width of trench � t .--------- -.------.- See it: Type of filter materia ---Depth of filter material----/ ------------f Total length- `_1FCa...- ........ ..... Distanceto / nearest _ J --_._Di rom fou dation_ " ''®Distanc crest lotue ��._ Nu its._ _ in material _ ize: Diame p g f ems'' 'r Cesspool: Distance from nearest well._..-__._______Distance from fo nidation _________ _ _.Lining material.. . '..__ .• ____ - ---- ----------------------------------Li Liquid Ca acif .'�'i -----gals. ❑ Size: Diameter Depth q P Y-i ------ Privy: Distance from nearest well-------------------------------------------------Distance from nearest building__=___. -___._s____._-------._________- ❑ Distance to nearest lot line-------- --- --- •----- ------------------------------------------------------------------- Remodeling and/or repairingf(describe):--.-_ _ 5-- ------ ► .1a •----- --------------- - ---- --------------'+ ------ ------------------------------------------\ --------------------------------------------------•-- ; r 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)---- f _ -- _ _.e and/or B �--� - ,--,-- �" c' `- - ---- ---- --- ------- ----Title_ , Y:---- :• _: (Title) _- - ---- -- ------------------------ ----- 4Contractor) (Plot plan, showing size of lot location of system in relation to wells, buildings, efic., can be placed on reverse side): ,l FOR DEPARTMENT USE ONLY ' APPLICATION ACCEPTED BY------ -------- ___ DATE DATE REVIEWED BY------- -------= ---- --- ----•------------------------- ---- BUILDING PERMIT ISSUED --- ------ - --- - ----- ------------------------------- ------------- DATE--- --------- ----- Altera ions and or recomm dations: -- ------------- ------------------------------------------------------------------------------------------------- 'W ---------------- ------------- o /0 .2l .-.. '� ------------------ --------------------------------- --•-•--------- - ,t -;� . Y ----------------------`----------•------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- ----------------------------------------------------------------------=-------------------------------------------------------------------------------------------------------------I--------------------------------------- • i . FINAL INSPECTION BY: -r!._- -lo -------- 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 Revisea 1.57 F.P,CO.