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tAAPPLICATION FOR SANITATION PERMIT Permit No. 5' __7a--` .. (Complete in Duplicate) - Date Issued __.yX_�__l___ Application is hereby made to the San Joaquin Local Health District for a permit to construct and install he work herein described. This application is made in compliance with County Ordin ce No. 549. JOB ADDRESS AND ATION -- / Owner's Name --= ne -- --- ----------------------------------------------------------------------------------------------------Address �1�� x E ��Z ��-- ----z Contractor's Name----- - -- L ------------•------•------- ----- ------------------- ; �y Installation will serve: Residence ❑ Apartment Housp ❑ Commercial Trailer Court ❑''Motel Other E]Number of li*ing units: _ °___ Number of bedrooms -Number of baths _ _ Lot size :,Z_/Il ............_________________________ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table',-? ft. Character Rf soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: Yes ❑ NoX New Construction: Yes,0 No ❑ FHA/VA: Yes ❑ Nom( TYPE OF INSTALLATION AND SPECIFICATIONS: I (No septic tank or`cesspool permitted if public sewer is Available within 200 feet.) Septic ank: Distance from nearest well--------•--------Distance from foundation_____________rt_77'ateriia7-7---------------------------------------- No. of compartments------------------------------------------------Size depth------------------------' Capacity----------------------- ' �. Dispos eld: Distance from nearest well --___-______Distance from foundation___--_____________-Distance to ryeerest lot line_________________ Number oflines-----------------------------------Length of each line------------------------------Width of trehA----------------------------------- Type of filter material--------------.----------Depth of filter material------------------ __-Total length_+___________.,__:r----------------------- ' 1 Seepa Pit: Distance to nearest well _____Distance from f ndation Distance to'nearest lot lxiner.___ P 9 - 17------------Depth----. : Number of its_____ ____-________ Linin material .� Size: Di star___ -_-_-_-_-_- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material____________________________________ e,' ❑ Size: Diameter-------------------------------------Depth---------------------------------------------------Liquid Capacity----------------------------gals, Privy: Distance from nearest well-------------------------------------------------Distance from nearest building----------------------_--------------------- 0 __________-- _❑ Distance to nearest,lost line--------------------------------------------- Remodeling and/or repairing (describe):__ y� ------------_................._...................•------___-__-__-___-___•-_-_•-__-__-__ _--___-__- -------- ----------- -------------------------------------------------- - --------------- - --------------------------------- -- _________-_-________.___________________________ _______________.__________________-______________________--_____ __-____-______________________________ _________-- __-______ I hereby certify that I have prep rea-tTi1 applicatl and that the work will be done in accordance with San Joaquin County ordinances, State la and rules a regulatio of t an J quin Local H Ith District. (Signed)_-C ----- -- " ------- - (Owns a r Contractor) ------------- -------- l , BY: ,/ -----(Title) ------------ - - ------------ ------------- (Plot plan, sh w- size lot, ocation system i re tion to wells, buildings, etc., can be on revs se si FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----- -- ----- ------------------------------------------------_------------- DATE._------------ -------- <' REVIEWED BY------------------------ ------- - - - -- --- - -------------- ----------- ---- DATE-_ - BUILDING PERMIT ISSUED--------_------------- - ------ DATE.......... ----------------------------------------------- Alterations and/or recommendations--------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------•---------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------- -------------------------- ---------------------1 ----- --- --- -- -- ----- FINAL INSPECTION BY:. --------- ----- --------- Date--------------'--C------------ 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 . Revisea 1.57 F,P.CO.