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APPLICATION FOR SANITATION PERMIT Permit No. 1 (Complete in Duplicate) 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 Ordinance No. 549. JOB ADDRESS AND LOCATION--- ------------------------------------------------------------------ O ' Owners Name- ---- Q y-----•-/ -------- __2Y� � 4*4A------------------- ----------III----------------- -------- Pho ------------------------------------ Address------------------------------------ I Contractor's Name--------------- ------ L � Mmercial � � ------------------------------- Phone --------------------------- 104Installation will serve: Residence Apartment House ❑ Trailer Court ❑ Mot I E] Other ❑ Number of living units: __r--_- Number of bedrooms __._ Number of baths _�___- Lot size --- ------------------------------- Water Supply: Public system ❑ Community system ❑ Private [I Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam Clay Loam E] Clay E] Adobe E] Hardpan �- Previous Application Made: Yes a? N'o ❑ New Construction: Yes n , No ❑ FHA/VA: Yes ❑ No ❑ TYPE 011INSTALLATION AND SPECIFICATIONS: " Ajj r "—, (No septic tank or cesspool permitted if public sewer is available within 200 feet.)z Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------Material---------------------------------------- -- __ ___-__. El �k No. of compartments------- -------�!____ -lO�Sl S�e--------------------------------Liquid dep{th--------------------------Capacity----------•- Disposal Field: Distance from nearest well_ ___ __.__Distance from foundation -_. __.__.Distance to nearest lot)inet�.____._...� Number of lines_-_ ._ _f? � Length of each line_____-______ Width of trench_�:�---------------------- Type of filter material�a_�4'•�C,.a_.Depth of filter material-----/K__----------Total length-------4�;p---------_--_--_------- Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line----------------- ❑ Number of pits---- -----Lining material--- -_-.-- Size: Diameter-----------------------Depth------------------------------ Cesspool. Distance from nearest well________________Distance from foundation________--_.-------.Lining material--------.-----------------_-________- 0 Size: Diameter--------------------------- ----------Depth----------------------------------------------------Liquid Capacity-.-------------------------gals. Privy: Distance from nearest well________________________________ ____________Distance from nearest building___-_____-__________________.._________- ❑ Distance to nearest lot line ----------------------------------------------------------- Remodelinf=#�Y� `f t� r�• i g 9;41 --------100 = � f. d_l a�$ f!► = � �-4- `f'-::'l.'' = .I * _er!--1--------------------------------------------- --------------------•---------------------------•----e?------ -------------------- -------------- ------------------------------------------------------------- ------------------------•--------------------- ------------------------ ----------------------------•-------------------------------------------------------- -------------------------------------------------------------------•--------------------------- -------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State s, a . rules and regulations of the San Joauin Local Health District. f t (Signed)----- - ---- -------------- -------- ---- -- - --:� -- -------- ------------------------------------------------------------------(Owner and/or Contractor{ -- By------------------------------------------------------- -------------------------------------------- -------------------------(Title)---------•------------------------------------------------------ (Plot plan, showing size of 1 t location of system in relation to wells, buildings, etc., can be placed on reverse side). __.,,FRRREf' RT T USE ONLY APPLICATION ACCEPTED BY___ ____________ -�- .__ _- Cr_ ^j .__ �! _. ----- DATE_-// REVIEWEDBY------------------------------------------------------------------------------------•------ --------------------------------- DATE-------------------------------- BUILDING PERMIT ISSUED------------- -------------------------------------------------------------------•---•---•------------ DATE---------------- '----- Alterations and/or recommendations:------------------------------------- --------------------•---------------------------------------------•--------•---------...------------------------------- ----------------- - ------------------------------------------------------------ ------------------------------------ ---------------------------- -----------;-------------------------------------- - -- - ---- FINAL INSPECTION BY------------------ h - ti --------- Date------- ----------' -- ---------- 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 ES-9-2M Revised 1-57 F.P.M