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4 — . r� �� (Complete : .. ---�0---�I I • APPLICATION FOR SANITATION PERMIT Permit No. ( p ete in Duplicate) r�� { Date Issued_______-9 --- Application is hereby made to the San Joaquin Local Health District for a permit:to'canstruct and install the work herein described. This application is made in compliance with County Ordinance No. 549. it F JOB ADDRESS AND CA ION Owner's Name -' Phone AddressAddress 4----------------------- -------------------------------- G 6 --------------------------------------------------- ------------------ Contractor's Name !f----------------f -------------------------------- Phone-•---•------------•------ ----------------- ---------- Installation __ C Installation will serve: Residence E"Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of livingunits: _ .__ .. Number -of baths/ Z -- Number of bedrooms _'Lot size _ ----------------------- Water SuPPIY� Publics stem Community system ❑ Private Depth to Water Table ft. I Character of sol! to a depth of 3 feet: Sand ❑ Gravel ❑"f Sandy Loam ❑ CIay�Loam Clay E] Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Const uction: Yes �o ❑ ,FHA/VA: Yes [ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 fee};) �. Septic Ta Distance from nearest well --------Distance from foundation__,/P-____ ____.Matyial_ ��-__- � e ,�� No. of compartments---_ :___�__--------Siz _�_ ------Liquid depth_-� r - ----Capacity-- !?j1C5------- p - g n___6y/-----Distance to nearest lot l e_.14 C . ------- is -------- Disposal Field: Distance from nearest well,'r -- __-__ Number of lines_______________________ en th of each line__ �p ----------Width of trench---�-J��------ -------------- Distance from oundatio Type of filter material De th of filter material__ '0'' { � --._-___-.-Total length__-- 'A � ` i Seepa it: Distance to nearest well___._./le._ Distance fromsf ndatln__- 49.__..Dista c to nearest IQt linelr__--�' . r � -_ Number of pits----_1`"-------------Lining material. {e ----Size: Diameter__��_-__...___.Depth__. __�--_______--._____ Cesspool: Distance from.lnearest well----------- "'Distance from fouetion--------------------Lining ma+erial_______________________-______ I ---� ❑ Size: Diamete r'N { :. ==-------------------Depth----- ------- ------- ------------------- -----Liquid Capacity gals. Privy: Distance from nearest well-_-____________ ro.m nearest building - ------- - Distance to nearest lot line_ ------------- &-.4 ARemodeling and/or repairing (describe): -- ------------------- --------------- - --- --•---------•------------------•---------•--------•----•------------- I ------------ --------------------------------•------------=a------------------------ ------------------------------------- --------------------------------- ---------------------------------------------------------------------------------_------------------------------------------ ------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I ordinances, State laws, and rules and re ula+ions of he San JoaquinLocal Health District. F (Signed) �j� -- --- --- - BY� ". 4Z ` - I ,y�f� r Contractor) -.-(Ti+e)--- ------------------ . r . '(Plot plan, showing size of lot, location system in relationJo_wells,-build ings, etc. -can placed on reverse side). ti. FOR DEPARTMENT USE ONLY u APPLICATION ACCEPTED BY-------- -- ----------------------------------------- -fi DATE 7- ------------------------------ REVIEWED BY ---------------- - ------------- DATE ` BUILDING PERMIT ISSUED---------------------------------------------------------------- ------------------------------------ DATE-- �------------ -------- Alterations and/or recommendations_________________________ - ------------------------------- ------------------•------------------------------------------- ----------------------------- ----------•------------------- -------------------------- FINAL INSPECTION BY:___-_ __---___- "# -- -------- -------------- Date---- SAN ate--SAN JOAQUIN LOCAL'HEALTH DISTRICT {{ j 130 South American Street 300 Wes} Oak StraetI X132 Sycamo Stockton, California Lodi, California re.Street i'�\ 814 North "C" Street ' ' Ment ea;Califorri'iat—'-,' t Tracy, California # E5-4-2M Revises 1-57 F.P.CO. i