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i .�' APPLICATION FOR SANITATION PERMIT Permit No, 'IComplete in Duplicate _ Date Issued .- 5 �%- Application is hereby made to the SankJoagGin Local Health Disfrict for a permit to const uct and install the work herein described. This plic apa+ion is made in compliance with County Ordinance No. 549. + # : - JOB ADDRESS AND LO ---------- Owner's Name _ - --- Address_--------- I�_ ( _ ---- ------- - —Phone -- ------- ------------ --------------- . Contractor's Name.....s-------�- t • ' k. • ----------------------•--------•--------------------.---------••--. -------------------- ------------------- Installation will serve: Residence Phone.-,.... ____"----- . ��Apartment House [] Commereial-�❑ Trailer Court ❑ Motel ' Number of living units: _-A- Number of bedrooms :_ � f' - of s ❑. Other ❑ - -. _...... of-baths " -_"-- Lot size ........ Water Supply: Public's stem -------------------- ,.�.,� 'umber Y l� �•ommuriity system ❑ Privafe� (}epth to"Wa4er Table"ys_ ft: ; Character of soil to a depth o0 feet:{ Sand ❑ Gravel ❑ Sand ~Loam µ M Previous Application Made: Yes 'No - y , ❑ Clay Loam .❑ Clay ❑ Adobe�rdpan ❑ ❑ [P--New Construcfion r-Yes z _ ❑- No [�►'I=HA/VA: Yes ❑ No 0� TYPE OF INSTALLATION AND SPECIFICATIONS: _ ' . f �4- t -� (No septic tank or'cesspool permitted if public sewer .is availabfe� ifhin 200 feet.)4 : tic nk: Distance from- earest well^"-, _�"_-- 'c fro foundation "- Distance from ______________". __.Materiai_:_____.- No. of compartments ------ -._ Size--------------= Liquid depth - Capacity = `"''" * r ; � t r _ os Field: Distance from nearest well ' f Distance from' foundation____-:__-_.__._-_-.Distance to nearest lot line_________________ Number of lines--------------- _,_- --___3.__"----Length of each line--------------- ___ }--.Width of-trench-------"-""---" x, Type of fitter material----------------------- Depth'of filter material-------- --------_ --.Total length_'-------,-------- F _ _ _ .Y ..�. - Seepage Pit: Distance to nearest well_ Lirq- 1 7 N umber of pits-------/------------Lrning material---- j __.Size: /O`", `Distance to nearest lot Brie__-""" ----- 1 'stance m f undatronDiemeter°"_""-- Q"`�----.Depth___. !-------------- p Cesspool: Distance from nearesf well______"-_ 1 ►�+ Drstance from foundation._._:__-_:."__ Lining material-__-__"___ ❑ Size: Diameter__--------- =----- x Depth ----- ---------------------------- (� �°- -- Capacity gals. l Priv #\ i t .-.�. t tg fl t ` � t building ----------------------------- s ❑ Distance to nearest'-lot lime- ------= ------- --:�__------•------------------------------------•--- -- �=--'------- - ,.. .._.�.,�,. . .; Distance fro nearest well::'___'__---.___"__-._ __-_ - ----:--_-Distance from' neares Remodeling and/or repairing (describe:----------------------- _- i T ------------------------------•-•--------•-------------------------------------- ---------------------------- , I i .y. ..�, t : -------------•----- -- ---------------- -•------_.:_ _ --------•-------------- ----- --_ ------------- -----------•--•-------•== --------------------•----"---- ---•------- I herebycertify that I have re ared this a hcatron and that the w I 4 s + __ _ ____ ork .... ypp g ------------------ --•----------------•-------------•-._... ------ ordinances, a laws and rules and regulations of the San Joa 'uin Local Hera114heDistnictry accordance with San Joaquin County Si ned - w , ----------- I i- " 1 r ----- -- --- (Owner and/or Contractor) By:.---------_-------•------------- ----------i . ------- ------- --�------- ---- -----� True ' ( � ) (Plot plan, showing size of lot, lots+ion cf system in. lotion to wefts; buildings, etc., can be placed on reverse side-- ! FOR DEPARTMENT. ONLY' APPLICATION ACCEPTED BY-------------° - ` + --- - -- -- -""__-- - - a---i---'---T-- --=------- REVIEWED BY - DATE �,rq_DATE------- a F BUILDING PERMIT ISSUED -;---:-_-- ----=---------------------------------- DATE.------- .Alterations and/or.recommendations: ----- -•----••--- ----•_--- I ------------ ------------------------------ ---- ---------------------- FINAL iNSPECTfON:BY:_-_- -- --- -------- Date_ - _ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street Stockton, California 8i4 North "C" Street Lodi, California Manteca, California Tracy, California ES-9-2M Revised 1.57 F.P,CO.