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APPLICATION FOR SANITATION PERMIT Permit No. !tU37 --------------- 1 (Complete in Duplicate) _ Date Issued ___ l7 /S_� Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This'Capplication is made in compliance with County Ordinance No. 549, JOB ADDRESS ANp TION ___---�/ _- ---------- -" 01 Owner's Name_ - -----------•------------ - --------- ------------------ ------------------------------------- Phone- y Address_._____ VVV ! Gonfactor's Name----------- -- - --- ------ ----------------------- --------------------------------- ------------- Phone -------------- Insfallafion will serve: Residence (��parfinenf House E] Commercial El Trailer Court E] Motel ❑ Other E] i Number of living units: _/-__ Number of bedrooms aZ Number of baths - -- Lot size ----- i i s��_� •-- Q ------------- Water Supply: Public system P ommunify system ❑ Private ❑ Depth to Water Tablei�t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 9j---H-`ardpan ❑ Previdus Application Made: Yes I] No �ew Construction: Yes ❑ No 0 FHA/VA: Yes ❑ No E] TYPE OF INSTALLATION AND SPECIFICATIONS: �4 (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) pf Tank: Distance from nearest well-----------------Distance from foundation--------------------Material __"_____________________ i ----- No. o compartments--------------------- --Size----•------------- ------------Liquid depth--------------------------Capacity------------- �-------- . pos field: Distance from nearest well__ _____ Distance from ---Liquid to nearest lot line_______-________ ' i js� Number of lines ---------------Length of each line------------------------------Width of french----------------------------------- V/ Type of filter material---_ Depth of filter material Total length------------------------------------------ ageSeepPit: Distance to nearest wellrlfOyt,Q Distan fo ndation_ /Q// ,�a_____.__..Distan e to nearest lot line_,11f____" Number of pifs_--___�.__-_-_____Lining material___ Size: Diameter_--__ ." p �� i -- - - ------Depth— � .------------------ Cesspool: Distance from nearest welf___-__-______--_Distance rom foundation____________________Lining❑ maferial_____..__-___.____".____ ----------- 1 Privy:;' Size: Diameter--------------------------- - ------Depth--------------------------- --- --- �---------- - Liquid Capacity-------------------- -----gals. Distance from nearest❑ well __ _Distance from nearest building------------------------------------------ ---------_--Distance to nearest lot line_-- _____-_ -_ " Remo eling and/or repairing (describe):"_______________________ ---------------------------------------------------------------- ------------------------------------------------ ------------- ------------------------•-•------- ------------------------- -------------------------------------------------------------------------•-----------•-------------------------------- --------------------------------------------------------------- I hereby c tify that I have-prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Ste i ws and,ruIesand reg ations of the San Joaqu' Local Health District. (Signed)--------- Owner and/or Contract By--------------- (Title)__ or) 'C -------------- -- (Plot plan, showing size of lot, location of system in relation wells, buildings, etc., can be placed on reverse side). Il. �i FOR DEPARTMENT USE ONLY APPLI1ATION ACCEPTED BY_________ -__` DATE---.-I. REVIEWED BY--------------------------------:�------------ ---- ------ ----------- ---- ----- ------------ ------------- --------- DATE---- ---�------------------- - BUfLDING PERMIT ISSUED------------------------------------------------------------------------- --------------------------------------------------- DATE----------------- ------- ---- ------ --------- ---------- Alferations and/or recommendations:___-__._-----.__-- k r- - --------- --- --•----------------------------------------------- ------ ----------------------��- 1��*-7�E-I s-- jG_-k 1 ------------------------------------------------------------------- - G-h+T_.-------441NJr-•--------T-0----------r �7------0-'K----------------F-11VA(-------------------------------------- -----------r ii•---------------------------------------- J ---- ----------------- ----- FfNAL IN BY Date--- SAN JOAQUIN LOCAL HEALTH DISTRICT 130:1 South American Street 300 West Oak Stree+ � !32 Sycamore Street 814 North "C" Street istock+on, California Lodi, California Manteca, California Tracy, California ES-4-'-2M , Revised 1.57 F.P,CO.