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s1 r APPLICATION FOR SANITATION PERMIT Permit No. .......... (Complete in Duplicate) - 1 _ e Issued Dat I 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. -- *� , s . JOB ADDRESS AND LOCATION frl J /�//'� f ------..ve -- n Owner's Name------ ------------------------------------------------------------------------------- - -- ------------------------- ------ .,..��- Phone I <�Add . "' ress--------&4c 7 ---- ---------------------------------- Installation A------- --------------- --------------- - I ------ 4 --------------------------------- Phone----...-------- NameContractor's Ad . ' . ---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _�_.__ Number of bedrooms_-_ Number of baths J--- Lot size f` `�___-_______--------------_.__ Water Supply: Public`system.❑ Community system g3�'Frivate ❑ Depth to Water Table/__ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy.Loam ❑ Clay Loam ❑ Clay ❑ Adobeardpan ❑ Previous Application Made: Yes ❑ No �' New Construction: Yes R;--No ❑ FHA/VA: Yes J!�— 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 welLs�Distance_from foundation'-_J410 -----Material---- ......... -___-__Liquid depth -._ Z--------------Capacity.-._ ____. No. of compartments__ _01------------------Size_si1 _ _ � �( __• Disposal field: Distance from nearest well /1,0 Distance from foundation--------r-------Distance to nearest lot line___�7_._. Number of lines--------A. . engfh of each line,�'J '_._'��----Width of trench.--_-_-9�``*--- __--._ Type of filter material_/ _ epth of filter material.-/9 _Total length------- -- Seepage Pit: Distance to nearest wellDistance from fou ation__._T ....... 's nce to nearest to line_f� OW - Number of pits_ ____Lining materia/��.____ . _ __. ize: Diameter_ -.,_..__.Depth------ r Cesspool: Distance from nearest well___________-__Distance from foundation____-..____-..._..Lining material_-______---_---------------_----. F -- ❑ Size: Diameter-------- ------------------------------Depth------------------- `---------------------------Liquid Capacity--------------------- -----gals. Privy: Distance from nearest well---_----_---_------------------------------------Distance from nearest building----------------.-_-_---__.-______-. --. ❑ Distance to-nearest-lot line=----------------- =--- ----' ----_------------= ----------------------------------- -------------------------------------------- t Remodeling and/or repairing (describe) r - ----- - -------------------------------------- er✓/�' - d -� -- - - ------ _---- - - --------------------------•------- --------------------- - ----------------------------------- -----"--.,x------- -- ------------'•----------------•----•-------------•---•---•---•--------------•------- -------------------—---------- ---------------------—--- -----------------Pp -- ---- ---------------------------------------•. .------------------.-------------------------- ---------•-------------------------- I herebycertifythat I have prepared this application and that the work will be done in accordance with San Joaquin uin County ordinances, State laws, and r les and regulati s of the San Joaquin Local.Health District. _ (Signed) -- ---- -- - -"�'r -± � Con}ractat) . By:....-............................. ----------- ------- - (Tale)- � /�-/� -- - - - -- ---- - -- -- ----- ---------- (Plot plan, showing size of ocation of system in.relation to wells; buildings, etc., can be placed'on reverse de). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----'.-- ---- --- -- -- -- -- --- ---- ------------------- DATE----- - !_ ._ Xcl REY)EWED BY-------- ---------------------- - _ --- - ----- ----- DATE----- - -- 6 -- ...--- BUILDING PERMIT ISSUED------------- ---- --------------------- --------------------------------------- DATE------------------------------------------ -...---------- Alterations and/or recommendations: - - ---------------------------------------- ----------------------------------•--------------------------- 1 R -- -------------------- ----------------------------- -- -- ---------- - ----- --------------- - ---- ------- ---- ------ ------� ------------ ----------------- ------- -------- -- ----- ---- -------------------------------- I 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 e ES-9-2M Revisea 1.57 F.P.CO.