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i t '} APPLICATION FOR SANITATION PERMIT Permit No. ` - (Complete in Duplicate) Date Issued ___ ______ ______ --___ I �', pplication 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 ADDRESS AND LOCATION..••. - ------ ------------------ ----------------- il, Qwner's Name j4Phone------------------------------------ --------------- - ---------------------------------- - ,II. Address-------------------------------xf�4------=----- .c -------1� ��5— '-----------------•------•------ -------------------------------------------------------•---••---- s , Contractor's Name----------` ` !! -------------------------------------- -------- Phone----•-•- �lp Installation will serve: Residence 'Apartment House ❑ Commercial ❑ Trailer Court [I Motel ❑ Other ❑ taterNumber of living units: _ _--- Number of bedrooms __ Number of baths __f__ Lot size ___ _,r _!_ ______________________ __ Supply: Public system ❑ Community system rivafe F'] Depth to Water Table -/4/ ft. � haracter of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay [I Adobe aHC3ardpan i i �Irevious Application Made: Yes ❑ No R-__'New Construction: Yes g?"No ❑ `FMA/VA: Yes @R`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----- ____Distance from foundation----I_P-___._.Material---------- �r_ �^ No. of compartments------- I 9- ------------ {�__:_--Liquid dePth------ �_'-----_-__--Capauty./�_� l_-. isposal "I Field: Distance from nearest welL.. r~____Distance from foundation----4!9'___------Distance to nearest lot line-----------_____ �� Number of lines___.______�..__-__.__________Length of each line...... ----------- Width of trench-------- Type ............... li Type of filter material--/ p g - .ft?Q� -De th of filter material_____�,�_�_____Total len th_____f�=�_/__________________ Seepage Pit- Distance to nearest well----- -----__Distance from foundation__30-_..-.___.Dista Distance to nearest lot line_________________ � � Number of pits._____--L----_______Lining material__/��-Size: Diameter____�� p ---------_.Dept r ! •I IIV%%'?" Cesspool: Distance from nearest well_________________Distance from foundation--------------.____Lining material__.'__..__________.__.._____________ ❑ Size: Diameter-------------------------: Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well- -----------------------------------------Distance from nearest building----------------_---__---_--__._-________- ❑ Distance to nearest lot line----------------------------------------------------------------------- -------------------------------------------------------------------- Zemodeling and/or repairing (describe):_ �••��e� � r v N ----------------------- -------------------------------------------------------------- , - --------------------------------------------------------------- ----------------------------------- --------------------- ----- -------------------------------------- I- -- - - -- ---------------------------------------- I' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County lordinances, State laws, and rules and regulations of the San Joaquin Local Health District. it I ilSigned}----------�J -------------------------------- - -------------------------------------------------------------------(6 d&r Contractor) III By:----------------------------------------------- - ------- (Title}---- /If/a= (Plot plan, showing size of lot, location system in relation to wells, buildings, etc., can be placed on reverse side). 44 llll FOR DEPARTMENT USE ONLY It li PPLICATION ACCEPTED BY-------- O- ----------------------------- DATE------..0 r----------------------- t REVIEWED BY----------------------------------------- ------ ------------------------------------------------------------- ------------- DATE-------------------------------------- --------------------- BUILDINGPERMIT ISSUED---------••------------------------------------------------------------------------------------------ DATE------------------------------------------------------------ U1lterations and/or recommendations:------e----------------------------- - --------- -------------- - ----------- ••----------------------- -- ------- I�'......--�1-7------ A TFL �`�. - X41 � 7 p ----4� /-------_-------. r ��1 >. --------- ' t1 j 1_t�tkM �-iv----- Cr*fL 1- i` C _L— r .-- LfV s � -------------- 1= Q t-- --'�` _1a( ----OA' r�- ------ —- -----�--------' r ------------ .�i._n_..--------- ----------------------------------------- ---- --- ------------------ --` - --------- - ------------------- ' -- --- -- -- ----- ---- Date------- rJ `�A- -------------------------------------------- I . FINAL INSPECTION BY� __��.-.-_- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore S+reef 814 North "C" Street i Stockton, California Lodi, California Manteca, California Tracy, California i ES-9-21x1 Revised 1-57 FRCQ.