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I APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) .�� '"�^ pate Issued Application is hereby made to the an Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in com line vith County Or In n e No 49, c J�4B ADDRESS AN &,A *T �( 9__. C�QVi_�.__ -( "W. -- ----------- f -------- Owner's Name --------- '-------•---------� -------------------- ---------------------------- ----- Phone----------------- •--------------- 'll. Address------------ - - -- ---- UA Contractor's Name------- - ------------------------------------------------------------------------------ Phone-- Installation hone•Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: __. ____ Number of bedrooms __ __ Nurriber of baths __Z Lot size _____ __ `________________________________ ,SII ater Supply: Public system ❑ Community system ❑ Private [t' Depth to Water Table _ - ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam [Er Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ aI� Previous Application Made: Yes ❑ No [� New Construction: Yes [�No ❑ FHA/VA: Yes [:] No P/ y� PE OF INSTALLATION AND SPECIFICATIONS: 111'i (No septic tank or'cesspool permitted if public ewer is available within 200 feet.) Sept Tank: Distance from nearest well-___ __.__Distance from foundation____/P----------Mat Tial________ _________ II [� No, of compartments_------ .---___-�-Size___-- X ___--Liquid dept------ ............. -----Capaci -�-- _ t r (� blspos I Field: Distance from nearest well...��......D•rstance from foundation_ ____/�______.Distance to nearest lot�ne._- ----------- 141— _________ -" } 1 T e of filter material______ L ngth of each line_________��rrr________.1Nidth�of trench.___ F ---------- Type --------- i i t Number it lines-------- Lepth of filter material _____________Total length______.�i _________________________ Seepage Pit: Distance to nearest well----------------------Distance from foundation------------.-----..Distance to nearest lot line i� ❑ Number of pits----------------------Lining material----------------------.Size: Diameter__._-------------------Depth--------------------------------- sp � Ces❑ool: Distance from nearest well_________________Distance from foundation._.________..___.-.Lining material___.__._-^---------.--------_---_-- fSize: Diameter-----------------------------------.De th--------------------------------------------------._Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------_ Distanceifrom nearest building____._______________________.._______._. ❑ Distance to nearest lot line - -=- ---------- '- ---=-------------•---•--------=-------------------------------------------------------- !�I k Remodeling and/or repairing (describe)=----------------------------'--------------------------------------------••--------•-------------•-•--------------------------------------------------- 4 ---------•---------------•----------------------------------------------- :--- --------------------------- d ------------------------------ ----- ------------------------------------------------------------- i I hereby certify that I have prepared-;this application and that the work will be do" in accor________________________________________________n - dance with San Joaquin County f Ilordinances, State laws, and rules and regulations of the San Joaquin Local Health District. II (Signed) !X -------------------(Owner and/o Contractor By:------------------------- ------------------------------------:---------------------------------------------------------------------(Title)---------------------------- ----------------------------------- (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 NL'Y ""`�'" APPLICATION ACCEPTED BY------------------------ ! DATE----- �r ----- REVIEWEDBY-------------------------------------------------- - -------------------------------------- DATE---------0- BUILDING PERMIT ISSUED---------------------------- ---- ---- --------- ---------------- DATE ------------------------------- --- -- ----------- Alterations and/or recommendations:--------------------------------------------------------------------------------------------- ----------------------------------------------------------- JG .11I . IM--------------------------------------------------------------------- -----------------------•-------------------------- -----------------------------------------------------------•- ------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- iFINAL INSPECTION BY: d �� --------------------------- Dated 'Q----- ! 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 I : ES--9-2M , Revisea 157 F.P.CO-