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i 41 APPLICATION FOR SANITATION PERMIT Permit n (Complete in Duplicate) / t 1�1 T DateR Issued a Application is hereby made to the San'Joaquin Local Health District fora permit to construct and install the work herein described. This application is made-in compliance with County Or finance No. 549. JOB ADDRESS AND LOCATION_----- .. ° ' _ --------- ------------------------ --------- Owner's Name -f'± 1r'= C- 44--v = - ----------- - ------------------------ ---------- Phone---- --------"--------- ---------- Address-----=-------- .-!I'' - - - `s - �t A". _ ► '� = ~ Contractor's Name- - i� �z==�:�a -- --- 4-1.1. -- - - 4 ------ Phone_7*:.__ _ � _A Installation will serve:" Residence ❑ Apartment House ❑ Commercial ❑ Trailer-Court ❑ Motel ❑ Other ❑ Number of living units: -------- Number of bedrooms ---------Number of baths .-------- Lot size -----------------------------------------------------_------_ Water Supply: .-Public system E] Community system El Private E] Depth to Water Table`.__-__'ft." F � Character of soil to a depth of 3 feet: Sand [❑ _Gravel ❑ Sandy Loam ❑ Clay Loam ❑. Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No ❑ New Construction; Yes ❑ No ❑ -PHA NA: Yes ❑ No ❑ . TYPE OF INSTALLATION AND SPECIFICATIONS: - -i (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) . . is Tjorfka- Distance from nearest well-----------------Distance from foundationMaterial-------------------------------------------------- No, of compartments �__�_ __ ' p --------Size--------------------------------Li Liquid .th--------------- --- -Ca acit Dis al Field: Distance from nearest-well__.--._ .Distance from foundation_ -I----------.Distance to nearest lot line----------------- ] Number of lines------------------------ ----------- Length of each line------ -----------------.Width of french------------------------------- 10 - .___ Type of filter material_______________ ______Depth o er er' :_-------------------Total length------------------------------------------ Seepage Pit: Distance to nearest well _1}_ �?--_Dish ce om foun afi ad:_..-..Dista nce to nearest lot line--. -_-- Number of pits------ ------------Lining„mate ;aL ....Si :'Diameter___.3_3_ Depth-=:- ---_r---.--.--_ Cesspool: Distance from nearest,.well_°:----'----__._Di tance from foun ation.----_p_-. .-___.Lining materia)-----------------------_----.--.-- Y - --- -- De th =---------- ---------------------------------Liquid Capacity----------------------------gals. Privy: DI stanDcle Fromr nearest well---------------__-____--___________--___�_ Dista?n'cee from nearest building �1 ❑ Distance-to nearest lot'line------------------------------------------------------------------------- ----------------------------- Remodeling and/or repairing i (describe)---------=-----------------------------------=----.-;-.-�- ---_•-.------.--_-.---. --------`-------=--------- -----------------•------------------.. - ------------ ---•---------•---------- I------- . ' --------- -------------------------------•---------------------------------- -------------------------------------- - ------------------------------- - ------- -----------I------------------------------------------------=------------------------- ------------------:-------------------------------------------------------------------- I --------------------------•----------------------------------------------"---------- I hereby certify t t I ave prepared this Application and that the work will be donein accordance with San Joaquin County _ ordinances, State law and rules and regulatiots of an Joaquin Local Health District. 1� _ --- -- {owner-a"fin �'br Contractor) (Signed) - - � SY: =------------= ---------------- (Title) - � . f. _dt: { -------------- ---- ------------- (Plot plan, showing size of lot, location of system in.relation to wells, building ;^etc., can be placed on reverse side). a FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------------------- --- -------------------------------- ---------------------------- ------ DATE----------------- REVIEWED ------- •---�F- REVIEWEDBY------------------------------------------------- -- - ------------------ --------------' -------------------------- DATE--------- BUILDING PERMIT ISSUED = ------'-------- ` - DATE ------ _ --- ------------------------------------------:_-------- AI#e ns nd/or�recommendations:�` - __ f•-T/p y /' L --•--- 'iI:� T ' "' �C..1_dt1- .. '�-- ----------------- ----------------------------------------- - ,�! ...16 6 /`��" 1 �1 ra .T'fi � ,,� iC - ��% �J..�fa_ -:4 ----•--- -- ----------------------------- ---------------------------- -------------------- -------- ------------------ ------------------------------------------------------------------- . , - ------ r` FINAL INSPECTION BY:.-,-_--- _-- -� ------------------ LTi-J. --- 5-- -- Date----�---- 1.� 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 f ES-9-2M , Revised 1-57 F.P.CO.-