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A d �: APPLICATION FOR SANITATION PERMIT Permit No. .......7C` _._... y � (Complete in Duplicate) Date Issued Application is herebydth made to e San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance wifb County Ordinance No. 549. JOB ADDRESS AND LOCATI N_Y�_ - J C� �'r.� -4 [.►, A -e------- ----------------- ------------------ --- I Owners Name - -4=�''-�------------------------------------------------------- _S - -----------------An----------------- _._ _J Address ----- 1 - --------------- --------------------------------------------- Contractor`s Name = Phone. -- ------- ----- ---------------- ---------------------------------- Installation will serve: Residence)*,Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel Other ❑ Number of living units: ...___ Number of bedrooms __�Y'Number of baths J--- Lot size � � __•--_J-_- Water Supply: Public system K Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [-I Adobe Hardpan E]Previous Application Made: Yes ❑ No K, New Construction: Yes '�No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well—V_i-Ywt�Distannc efrom foundation--- " • -•-----.Materiel-----'Qi:------ - - -�----_. No. of compartments ---------------Size = - -..� Liquid depth _I4-- Field: Distance from nearest well---V_1-QNvQDistance from founda ion. ..) ---------Distance to nearest lot ire -„! Number of lines---------- L th of each line__{ Q._ __ _..Width of trench_-__'_�r Type of filter material_._ _D of filter 'I Type _ --------Total length-___j_cf__D-------------------------- Seepage Pit Distanc's to nearest well- ____----____Distance from foundation--------------------Distance to nearest lot line----------------- El Number of pits--------------------Lining material--------------------Size: Diameter----------------------Depth-------------------------------- Cesspool: Distance from nedrest well-----------------Distance from foundation--------------------Lining material------------------------------------- ❑ Size: Diameter.__.. ________ Depth - Liquid Capacity -------gals. Privy: Distance from nearest well--------__' ---------------------------------Distance from nearest building------------------------------------------ 171 Distance to nearest lot . Rem eli or repairing` describe):___-__ , ----------------- --. ----- = = �.�...- -------------------------------- --- ------------------------------------------------------- -------------------------------------------------- ------------ ------ ------ - ---------- -- - - ---- 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) � ------------------------(Owner and/or Contractor) ----------------------------------------- B, si rev rse laced on- -- �7 . -- -- -- ---- -- -- - -(Title)-------------------------------------------- (Plot plan, o rh size of lot, loc.tron of system in relation to wells, buildings, etc., can be P 0 de). FOR DEPARTMENT USE ONLY --------------- APPLICATION ACCEPTED BY--------------------------- ---- DATE-- 7-------------------------------------------------- _ - -------------------------------------------------------------- REVIEWED BY - - N-�- ----- ------- ----------------------------------------------------------- DATE-- BUILDING PERMIT ISSUED--------------- ------- ----- DATE----------- Alterations and/or recommendations:___._.-..__ ------------------- -------------------- _ -- - <" - - ------------ -------------------------- ------------------------------------------------------------------------ ------------ -----------------._.----------------------__ ----- h r FINAL INSPECTION BY:.-__ ` Date.-- ------�.-._t% SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 014 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revisea 1.57 F.P.CO.