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APPLICATION FOR SANITATION PERMIT Permit No. .S.Z- �,� [Complete in Duplicate) Date Issued 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 Ordinanc No. 549. JOB ADDRESS AND LOC TIO .---------- ---- -- ------ --------- ------ ------ ,91 ---- ------------ - Owner's Name 1AA-VL----------------------------------------------------------------------------------------------------- Phone-----,&R• Address EaO ,a. ---------( -------------------------------- -------- -- Contractor's Name- -- ----- ---� --- _ -------------------------------------------------------- Phone_-ar.--4 --1?-� Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: A.... Number of bedrooms -"3' -- Number of baths -j-__ Lot size ---- X_1�,��-----------__________________ Water Supply: Public system ❑ Community system (t Private ❑ Depth to Water Table __' _ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 4 Hardpan ❑ Previous.Application Made: Yes ❑ No ® New Construction: Yes K No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) i Septic Tank: Distance from nearest well__/h•E*(_____.Distanca from foundation___. _D_._.._____.Material____ ________________________________________ No. of com artments_-..,-�---- --- -aze._____3_ KSS---7--------Liquid depth------�---------------Capacity---•-�-�- ------- Disposal Field: Distance from nearest well-_/n*f-------Distance from foundation__/_6".__.__.Distance to nearest lot line_-.__.___�.____. Number of lines___________ __ `� �--- �_________ ________Length of each line___.___7S____`�._____...Width of trench___.___�___._._______.____ r, Type of filter material--___10� _.___-Depth of filter material------/�-__----------Total length------ --___._.-_-__-_-_-_--- t: Distance to nearest well---A(-PljP_---------Distance from foundation_7�% ....___...Distance to nearest lot line__--____- fig Number of pits-------- _---------Lining material-____7-1 Ek k______Size: Diameter---- _---------Depth___J''_____----__-_________ Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material-------------------------------------- El Size: Diameter--------------------------------------Depth----------------------------------------------------Liquid Capacity.---------------------------gals. Privy: Distance from nearest well------------------------------------------------Distance from nearest building------------------------------------------ 0 Distance to nearest lot line--------------------------------------------- ---------------------------_----------------------- G I Remodeling and/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 p ordinances, State laws, and rules and regulations of the San aquin Local Health District. j (Signed)--------- - _wiz-�----- - --- --------------- -------------------------------------------------(Owner and/or Contractor) ! - ---- ------ ------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ -1------------------------------------------------------------ DATE------4 - -` ---------------------- REVIEWEDBY------------------------------------------- ...... -------------------------------------------------------------------------- DATE------------------- ------------------- BUILDING PERMIT ISSUED----------------------------------------------- ------------------------------------=----------------- DATE-------------------- I Alterations and/or recommendations:---------- ----------- ------ ---------------------------------------------------------------------------------•-----------------------------------•-----•--- -.-•---•-•----•---•------------------------•-------••-•-----------------.._-.-------- -------------------------•-•=•----•-------------•---•----------------•---------------------•-------------•---------------•--------•- I ---------------------------------•-----------------=-•----------------------------------------------•----------------------------------------------------------------------•--------- ------------------------------------- -----•-------------------------------------------------•---------------t------------------------------- --------------------------------------------------------------------------------------------------------------- ----------------------•--------- ••-----------------------------------------------------------------•------------------------•--------- l FINAL INSPECTION BY:. .._•_ •--------------. �� ------------------- ------------------------------ �.--- ---------•---------------- Date. -l�/ v 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 Revised 1-57 F.P.CO.