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�q ;APPLICATION FOR SANITATION PERMIT Permit No. _+_t_1____.._ (Complete in Duplicate) Application �s hereby made to the S' Date Issued A I p y an 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_. --41/d -JO 0�4/ - ; --------------------------- - - - - ---------- - - -- --------- - - - - -- ------------------------------------------------- Owner's Name ``-----"�`---------------------------------------------- ----- - ---------------- Phone---------- ' ---------------------- teAddress------------ --- Phone--- f f/ iI l Contractor's Name-- ----=- f ---•---- r------- ----•----- � •� .'ifi'�-� --- ------------------------- ------------ _ Installation will serve: Residence FA Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ____(___ Number of bedrooms :Z- Number of baths __.__ Lot size___%'ax____.________________________ Water Supply: Public system R. Community system ❑ Private ❑ Depth to Water Table -------- ft. Character of soil to a depth of 3 feet Sand [-]Gravel E]Sandy Loam E]Clay Loam E]Clay ElAdobe } Hardpan ❑ Previous Application Made: Yes E] No N New Construction: Yes N No ❑ FHA/VA: Yes ❑ No Pq TYPE OF INSTALLATION AND - SPECFICATIONS: oseptic tank eslp'dfp! sewer is available within 200 feet._) Septic Tank: tncefomnearest welpublic from foundation_f0__r_ ........ .Material ____r No. of compartments ------I -------- Size ----_-3_ 57 - ------Liquid depth------f-------------Capacity.... G�q; Disposal Field: Distance from ® nearest well___._ Distance from foundation --- L_V-_`_______Distance to nearest lot line__�_�_7__ /______ Number of lines___ _____ ---------------------- Length of each line-----VP-------------------Width of french ---- P.,k- ____ Suri Type of filter mafieriaL------ Depth of filter material --- /9--/-- ----------- Total length ------- 0------------------_------_ S Pit: Distance to nearest well_ --------_Distance from foundation___ 9' rlines3~ �- _ __._...__.-stance to nearest I� ----------------- Number ______ ___ �j Number of pits.-. --------- --------- - Lining material----OCr-/ ---.Size: Diameter ----• -r1------ --.De ------------------------------ - - r CesspooL- Distance from nearest well ----------------- from foundation ------------ _------- Lining material ---------- _-------_________._________- ❑ Size: Diameter----- I--------------•------- -------- Depth ---------------------------------------------------- Liquid Capacity ---------------------------- gals. Privy: Distance from nealrest we€I-------------------------------------------------- Distance from nearest building ---------- _________________- ❑ Distance to nearest lot line --------------- ---------------------------------------------------------------------------------------------------------------------------- Remodelingand/or repairing (describe);--------------------------------------------------------•-------------------------------------------------------•---------------------------------------- I -----------------------------------------------------------------i -. ••------•----------------------------------------------------------------------••-----------------------------•----------------------------- -- ---- -----------------------= -------------------------------------------------------------------•-------------------------------------------------------------------------------------------•------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat laws, and rules and 'regulations of the San Joaquin Local Health District. --- - 5�%, (Signed]_-------------------------------------------- ----------------------------------------- �--: ------------------ (Owner and/or Contractor) By-------------------------------•-------------'-------------------------------------------•---------------------------------------(Title)---------------------------------------------------------- (Plot plan, showing size of lot, location+of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- -I-------- DATE----- REVIEWED BY -�----------------------- DATE ------ ------------- BUILDING PERMIT ISSUED-------------------'--------------------------------------------------------- DATE - Alterations and/or recommendations:- 4--- ---------------------------------- - ------------------------------------------------------------------- -------------------------------- --,L---4-J&---=-�------- ------ -------------------- q --------------- - - -------------------- ------------------------------------------------------------------------------------------------------------------------ FINAL INSPECTION BY ----------------- -------------------------------- Date-----a---r A-�'- - 610- 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 , Revises 1-57 FRCO. I1 kg ft