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APPLICATION FOR SANITATION PERMIT ' 1 Permit No. . 1 (Complete in Duplicate) 7�y Date Issued .____ _�- ------ . ��_ Application is heIroby made to the San Joan Local Health District for a permit to construct nd int ls�l th�vro6ke ein described. This application is made in ce with County Ordinance No. 549. +I� �" -' 4 er -- '-JOB ADDRESS.AND LO ATION------'ef � # �00 -------------------------------------- ----------------------------- ---- ' ----------------------------------- Owner's Name-=--------- � ne Address---------------Z� Oee:------------------------------- � -----------------------------------------------------------------------Phone----------------------------------- V ---------------- --------------- -� Contractor's Name------- �, P�< -------- - ------ -------------- ------------------------------ Installation will erve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ __ Number of baths __ _ Lot size /��'� { Number of living units: __�`_ Number of bedrooms ,� ------------------------ W � - -------------------------- Water Supply: Public system Cl' 'Co Srmunity system ❑ Private Depth to Water Table �_ ft. Cfi Character of soil to a depth of 3 feeti,Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan L,;_,�� Previous Application Made: Yes El No ew Construction: Yes [ No ❑ FHA/VA: Yes ��No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: - (No septic tank or`cesspool permitted-.,if public sewer is available.,within 200 feet.) ,. F . I Septic T k: Distance from nearestwelk_�_!- _ �pistanc fffom''fLLoundation___49_________. ateea�_ _ - Gp.�--- _------- �P- Liquid depth p tY ld , 1 - `:----- Si3e Ca aci No. of compartments.____ `ti _ Disposal Fi Id: Distance from nearest weil_� _- Distance from foundati `,________.Distance to nearest lot line________--__ [ � Number of lines___.V___�____`_f___ __`____ Length of each line___ _____ ____.Width of trench.__ r_______°'_' - r�� Type of filter material__ De th of filter matenal____19 ______._Total length________. _ _ Seepage Pit: Distance to nearest well_//� Distance f m fo dation___ ®_______--Dist �e to nearest to I- Seepage 1 I /� p - Number of pits._'_._._________Lining materi ,_ :5ize: Diameter___ __ ________ _De th_____. _ _____ t Cesspool: Distance from nearest well-------.---------Distanae"from foundation--------------------Lining materia----------------- --------------- ❑ Size: Diameter--.- - Depth-----------------------------------------------------Liquid Capacity-----------------------------gals. Privy: Distance from nearest well--------.----- ---------------------iN,_._.._Distance from nearest building-_-_-_,___—__—___-______---_._._. ❑ Distance to nearest lot line.... - - ------------------------------------------ ---- ------- 1 � f Remodelin and/or re airin (describe): ----------------;--------------,-------------------- g / p g �--- =; r ---•-•----------------------�•- '----------------------------------------------------------- 1---�" * . --------------------------------------------------------------- - - I hereby certify that I have prepared this application and that the work will be done in lacco�dance with San JoaquinaCounty ordinances, State laws, aW d regulations of the San Joaquin Local Health District. f (Signed--------------------- ------- �� .. -- ----- - -- .r Contractor ------- - -- ------- ------------- �-�-- ----------------(Title)-----P --------------i------------ F By----------------------•--•------------------------------- ------ (Plot plan. showing size of lot, location stem in relation to wells, buildings, eta., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY A _-.-----f- -2g7A------------------------------------------ DATE------------------------------- ... g----------------- REVIEWEDBY--------------------------------------------------------------------------------------------------------------•--------._ DATE----------------------- ------------ ------------------ ---------------- DATE PERMIT ISSUED------------------------------------------------------------------------------------ DATE •----- ------------ Alterationsand/or recommendations-------- ------------------------------------------------------------------------------------------•---------------•---•-- ---•-------------------------------- ---- -- ---------------- - ---------- - ------------------ ------------------------------------------------------------------------ ------------------- ------------- --------.. ------------------------------------ ---------- -----------•----------------------------------------•-- � � -?- 2 , 0 FINAL INSPECTION BY-------------Aklln</Ylr-'---------------- t \ Date_.---------- -----------------•--- -----9---------------------------------- SAN`JOA UIN"LOCAL--HEALTH DISTRICT _-Q - 130 South American Street 300 West Oak Street 13T 5ycamoFe`St et '!�' 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES--9-2M , 'Revised 1.57 F.P,CO.