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00 4 APPLICATION FOR -ANITATION PERMIT Permit No. 90' - (Complete in Duplicate) Date Issued Applica+ion is hereby made to the San Joaquin Local Health District for a permit to con truct and install the work herein described. �''Jis application is made in compliance with County Ordinance No. 549. ff i JOB ADDRESS AND LO ATION 3 f1 F� - ... . --- 4- - ----------------------------------11 Name. , ' :... ;a�'r-� :: r'X ? P :one. - ----._ __---� f �a A _._ Address l ! dr t 'fy•= `' a ,------- /'� /. YY� ------------- Contractor's Name------------ •-- -n- - -- ------------------•-----------------------------•-------------------------------------------------------. Pone------------------------ Installation --.._._...----- - Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court I] Motel ❑ Other ; Number of living units: __ Number of bedrooms --//. Number of baths !—_. Lot size - f ------------------------------ Water Supply: Public system Community system p Private ❑ Depth to Water Table-dit. Character of soil to a depth f 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe` ' Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_________________Distance from foundation--------------.._--.Material------------------- ----------_------------------ F1 _______._--__._ .❑ No. of compartments------------ - ------- - Size----.---------------------------Liquid depth----------- Capacity----------------------- Disposal Field: Distance from nearest well-----------------D-stance from foundation--------------------Distance to nearest lot line___________-..__. ❑ Number of lines------------------------------ ----Length of each line---------------------------.-.Width of trench---------.--_---------------------- Type of filter material---------------------....Depth of filter material-------- __._Total length------------------------------------------- Seepage Pit: Distance to nearest well._ -±1,�_Distance rom f .ndation��.Dis.9 yr to Weare in --- Number of pits..___-- If__._-____.Lining material_ tr t!_ Size: Diameter._._ . ._._...___De er_. Cesspool: Distance from nearest well_________________Distance from foundation--------------------Lining material--------- _-____ ❑ Size: Diameter----------------- ------ - --------Depth---------------------------------------------------Liquid Capacity----------------------------gals. r'rivy: Distance from nearest well-------------------------------------------------Distance from nearest building.___.-_.__.__.______-________.__._____-_. ❑ Distance to nearest lot lire--------------------------------- -----------_--- ------ ----- - ---------------------- - ------- -- --------------------- ----------------- or epairing (describe):------ex- -------- "" "' t ..e. . ------------ --------- ---------------------- ----- ----------- ------•----------- --- --------------------------------------- -------------------------------------------------------------------------------------------------------------------------•- -------- I ereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, an rule regulat of the San Joaquin Local Health District. (Signed)-------------------------- --- ------ ------- (Owner,ond/or Contractor) By:--------------------------------- (Titl ------ � 2r'f'y'-"------------ (plot plan, showing size of to , location of system in relation to wells, buildings, etc., can be placed on revere side)' FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----...... -- -- - -------- - ---------------------------------------- DATE-------- -- REVIEWEDBY -- ----------------------------- ---------------------------------------•-- DATE- PERMIT ISSUED---------------------------- ------ ----- --------------�-------• DATE.- ---- ��' ----------------- BUILDING Alterations and/or recommendations:.__ ,' f.__ �--,Pr- : -__�_ s .___�w___ SAS___ -------- -- - "A---- -.n------ ---A---"y�---- --- - ----•---- - --- d' --- - � ------- ' r: - ------- ------ .___ -------------------------------- .___.__.___..._-._._.____....._...__w- 4 _ t - ------------ -----•--•-----_ .... , -=.. -�_._. .... � -- -------- ------------------------ - zt FINAL I INSPECTON BY:- = - --- -- - -------------------'----------- 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 EE-9-2M 145446 ATWOOO 12-54 1