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FOR17r.�1 E U� �F2- ----- -- f R� ___________ ______ ___ ___ _ --------Ir APPLICATION FOR SANITATION PERMIT Permit No. /�:ra........ x I'M - ---- (Complete in Duplicate) --------- I This Permit Ex ires ] Year From Date Issued Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinanc No. 549. JOB ADDRESS AND LOCATION .=Q 'tom-•- l" i Owners Name------ 5 ----=-- --- --------------------------------------------- Phon ----y7.VLX3. Address------------ - ------------------ ------------ ---------- ---- Contractors Name------ — .... D` �J ` _ ------ -•--••---- Phone _... .�� . . Installation will serve: Residence �Apa ment Ho se ❑ ' Commercial ❑ Trailetr Court ❑ Motel ❑ Other ❑ Number of living units: ---1. Number of bedrooms `Number of baths 2f_ ot,siz, ......± _-__j___-_/7_ __!2/-------------------- Water -................... Water Supply: Public system ❑ Community system [ PTivate ❑ Depth ro Water Table J0ft. Character of soil to a depth of 3 feet: Sand ❑fjGravel E] Sandy Loam L] Clay Loam ❑ Clay [3Adobe 0 Hardpan ❑ Previous Application Made: (If yes,date------------- I___-:]' No ❑ New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS:" (No septic tank or cesspool pWrmif ed if public sewer is available within 200 feet.) tia (IN: septic Distance;from nearest well........:........Distance from foundation_...-.__._._*'.__.-.Material_-.-._....---.-.._...------._------------_----._. N No. of com artments--------------------- ----Size.-i`----y--------------- --,Liquid depth------------------------- Capacity o field: Distance;from nearest welfj-RD.._...Distance from foundation.___./ ,..Distance to nearest lot line...... "+ Number of lines....._f g __ .... .... .......�.-:yy Length of each line..- _Q.r-.. Width of trench-----.�i_`�....!-----------_-- Type .-_..-._...... ' T e of filter material, r 1l._.De th of filter material.....__ .- Total length Q {` YP P �----- g � ---------------------- p g i Distance,to nearer wel ®®.�-.__Distance rom oundation----_Z_�_�..Distance to nearest lot line...._..�� Number of pits----- ---------------Lining material__ _..-.Size: Dia meter_��-_--.-..:Depth....2.d............_.._.... Cesspool: Distance'rfrom nearest well-----------------Distance from foundation--------------------Lining material..-.. ._._....___ ❑ Size: Diameter------------- Depth--------------------------------------------------..Liquid Capacity-----.......................gals. ► Privy: Distance from nearest well......-------...............__-..---------- -------Distance from,nearest building------------------------------------------ ❑ Distance to nearest lotline-------------------------------- -------------------------- -i--------- `--------------------------------------• -------------------...---•---•---------------------------- Remodeling and/or repairing (describe):-------- --- ----------- --------------------------------- t -•-------------••-._..---...-.-•-----------------:--`--------- ------ -- , `�-- --------------- ------------------- •------•-------------....-------------------------------.---------- ----------------------------------------------- ----------------------------------•--------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. (Signed Q-.. { ` er~......----- ------------------------------------------------ � Contractor By:•:=-----•------------------------------------------------------------------ ------------------(Title)---------------------------- ------------.......... (Plot plan, showing size of lot, location of system in relation t wells, buildi s, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY.._ �42'� - -- -- -----------— BY -------------------- DATE------------------------------- BUILDING PERMIT ISSUED-------------•---------------------------- J DATE-----------------------.. ..- ---- ----------- Alterations and/or recommendations:------ = -- --------- --------------------------- _��2- . --- ------------------------- r- �..._------- ------------------•------ = . f t Cre 4... `-z`v.. _... ._......' '��- ------ �4��--------- ----------------------------------- -----•-------•--•----------------- ----------- -----••------••-•- ..... --------------------•-•--......--•------•---------......--------....------------•----•---------- --------------------- --- ---------- ------ ---- FfNAL INSPECTIONBY:..'. _ ----- --'--- Date SAN JOAQUIN.,LOCAL`HEALTH DISTRICT 130 South American Street 300 West Oak Street ( ? 124 Sycamore Street 205 West 9th Strut Stockton,California 1 Lodi,California { Manteca,California Tracy,California ES 9 REVISED 8-59 EM 5-62 ATLAS