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APPLICATION FOR SANITATION PERMIT Permit No. t (Complete in Duplicate) . Data 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-•------ -- --- aA F � ----1 de ------------------------------------- Owner's Name Name r - -- -------- �C , - Phone- !GTfj Add ress-----------------------------------------•---- - --- -- ------ Contractor's Name---------- ••--------••--- �L�.kIL-k----�-r ----•------- --• ---------- Phone Installation will serve: Residence X Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ 9 Number of living units: -1------ Number of bedrooms _Y_ Number of baths .1___ Lot size __ 0_'__?....../.,;•o-�__________________ Water Supply: Public system )r Community system ❑ Private ❑ Depth to Water Table -4oft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobeg Hardpan E] Previous Application Made: Yes ❑ No X New Construction: Yes ❑ No ❑vs4t f �� TYPE OF INSTALLATION AND SPECIFICATIONS: e (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 5 _ tic,,Ta k • Distance from nearest well------------------Distance from foundation-------------------.Material------------------ :_._.________..-..___._____.. (� No. of compartments------------------_ - Size___________ Liquid de th________ ---------------Caacit osal .ield: Distance from nearest well_--- ..........Distance from foundation___ '__':________-.Distance to nearest lot line---------------- Number of lines------------ -------------------!Length of each line------------------------------Width of french--------------,------------------_-� Type of filter material-__.________._. ,Depth of filter materia h______________._________________________- See age Pit: Distance to nearest well.�Opjk------._Distant ffr�fT��fgunclat n_ 7Diance to nearest lot line__.._____ of pits.___- -------- -----Lining material Lf�_ ! _.___Size eter- -------- Number Depth__, '_''_______._____. Cesspool: Distance from nearest well--------------- from foundation--------------------Lining material-___-_-.____________________________. ❑ Size: Diameter------------------------- -----------Depth----------------------------------------------------Liquid Capacity------------------ ---------g Privy: Distance from nearest well-------------------------------------------------Distance from nearest building-----------------------------------------. ❑ Distance to nearest lot line------------------------------------------------ ---------------------- ---------------------------------------------------- ---------------- Remodeling and/or repairing (describe)--------------------------------------------------------------------------------------------------------•--------------------------•------------------ ---------------------------------------------------------------------------------•----- ------------------------------------------------------------------ ---------------------------------------------------------------- ------------------------------------ -----------------------------=----------------------------------------------------------------------------------------------------------------------------------------------------------- ------------ ----- ------------------------------------ --------------------------------- ---------------------------------------------------•-----I------------------------------------------------- ----------- I here y cerci that have pre ared this application and that the work will be done in accordance with San Joaquin County ordinances, Stat ws, a d rules an egulations of the an Joaquin L al Health District. t (Signed) S. IV --------------------------------------------------- Contractor) By:----------------------------------------•------------ ------------------------- - hA1-- - -------- ----------(Title)--- - Z-l�--- - - O (Plot plan, showing size of lot, location of system in relati to wells, buildings, a c., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------ DATE----------- - - ----- - - - -- - REVIEWED BY - - -----------------------•---------------------------------------- DATE---------- BUILDING PERMIT ISSUED--------------------------------------------•-------------------------------------------------------- DATE--------__----------- Alterations - •----•----- Alterations and/or recommendations----------------------------------- --------------- •-------•--------------------------------------------------•------------------------------------------------ ---------------------------------------------------------------------------• ------------------------------------------------------------------------------------•--•--------------------------------------• -------------- -------------------------------------------------------------------------- ------------ ------------------------------------------------------------------------------------ ------------------------------------•- ---------- ------------------------- ------- -------------------------------------------------------------------------------•- ------- ---------------------------------------------------------------------------------------------- 'A FINAL INSPECTION BY------------- Irly r-? ----- - ------------ 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 10-52 Revised W-2100