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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) Date Issued -__!_�3.��/iS_., Applica#ion is hereby made to the Sam Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinarice No. 549. , JOB ADDRESS AN LOC TION = - •- ------ �� ------------------------------- Owner --- ----•----'-i--- Owner'\N--a--�me-�---------------C. --- ------C-X-----�-,------•-------------- _ J - - ------------- ---- PE Addr ass--- t-- --------- = Contractor's Name_____ ___�Y'��t___ ------ --------- Installation - -------------•=-------- --------- - ----- Phone Installation will server Residence Apartment House Q Commercial ,Ej Trailer Court ❑ Motel [1 'other 0" Number of living units: N tuber of bedrooms.1___._=Number of baths S1_-- Lot size __5�_ _- - -------------------- Water Supply: Public system Community system ❑- Private [] , Depth to Water Table"` -ft. Character of soil to a depth of 3 feet:1 Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ZD__1ardpan ❑ Previous Applica#ion Made: Yes ❑ No Ve-�New Construction: Yes to ❑ FHA/VA: Yes ❑ No } TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest-well-----------------Distance from foundat.ion---------------.____.Material______.___.-_________ _ ❑ No. of compartments------ ------------------ Size----------------------------------Liquid depth--------------------- Capacity . ' ---------------•---- Disposal Field: Distance from nearest well------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of lines-----------------------------------Length of each line------------------------•----.Width of trench. w Type of filter material--------------------------Depth'of filter material--------.--------------Total length--------------------------- Seepa Distance_to nearest well._ +- _:__Distance from f undation_ 0:_ __.__..D stay to nearest Igt�nee------- Number of pits---- ------------- Lining material__P Q IJLr--- -, Size: Diameter__ Depth___-- - ul Cesspool: Distance from nearest well____-,_________Distance from-foundation___________________Lining material-------------------------- ----------- ---_--_-- ! Size: Diameter ----- Depth----------------------------- --Li uid Ca aci Pr i y`` Distance from nearest well `d7°lD q p ___._ gals, (l-- ---------------- ---- Distance from nearest building___--3-------------------------------- Distance ___ Distance to nearest lot line___.___----------- ---------------------------------------- -----•----=----------------- Remodeling and/or repairing (describe):____ -------_-__ s - -- .` '---------- --------------------------------•--------------------------------- - ; ---- --------- ------------------- ---� -_ ----------------------•---•--------------------- ------------------------------------------------------------------•----------------------------------- I hereb cert' the have pre red this application and that the work will be done in accordance-with 'JoaquinSan Count Y�� ordinances! taf. aws, nod ales �d/.egulationVof the San Joaquin Local Health District. y 1 Signed]�-_• s( G'7 -------------(Owner and/or Contractor) Plot plan, showing size of lot location of s stem in relation to wells, buildings,BY= - ------------ ---------•--•----••--------------- z°-- ------(Title)---------------------- -------------------------- -=----- ------------------- ____ ( P g � Y a#c., can be placedon y.'e'nerse side):.-� • FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - •. -- DATE--__---- r ,,� __ REVIEWED BY _ 1 _r . . ----------- -------- DATE_ -. f BUILDING PERMIT ISSUED----------------------- --I\ - 1-0-1.1-el f ----------------------------- DATE------ l Alterations and/or.recommendations:-------. .______----- -------------------- - e I a - -------•-----•--------------------------•---•---------------- -------------------------------------------------------------------- 3 -----------•---••---------•-- ------ -----••---••---------------------•-- --------------------------------- ------- FINAL INSPECTION BY:._ Date --- - �S I ,--------- ----------- --- _ . SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Street 132 Sycamore Sfree+ 814 North "C" S+ree+ Stockton, California Lode, California Manteca, California Tracy, California l ES-9-2M , Revises 1-57 FY.CO.