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i APPLICATION FOR SANITATION / PERMIT Permit No. (Complete in Duplicate) D ate Issued 1��3�/; y Application is hereby made to the San Joaquin Local Health District fora e This application is made in compliance with County Ordinance No. 549, permit to construct and instal the work herein described. JOB ADDRESS AND LOCATION-_----- � ` ..........Owner's Name-------•-- -----------------------------� - -........-- Address__. ---------- -- Phone----- - _ p 'C7 -- -- ------------------------------- -- ontractor's Name . i -- Q ---------- ------------ Installation will serve: Residence ------ Phone•-_- --f Apartment House ❑ Commercial �� ---•- ❑ Trailer Court ❑ Motel 0 Other ❑ Number of living units: _, Number of bedrooms __'Number of baths -l -- Lot size _____-Water Supply: Public -system Community -system ❑ Private to Water Table3,�-—ff. 4 r. f " s Character of soil +o a depth of 3 feet: Sand Previous Applic Ilion Made: Yes El to ❑ Sandy Loam ❑ Clay Loam ElClay El Adobe Hardpan E]New TYPE OF INSTALLATION AND SPECIFIICCAATIONS;Construction: Yes F] No ❑ (No septic Tank or cesspool permitted if public sewer is available within 200 feet.) Sept Tank: Distance from nearest well_60*---Distance from foundation__/Q-__--_"-_ -,Material_."__. No, of com artments 4 ------ p Siz •-n.`F.Liquid depth--. -T f! dd �3vr -----CapacitY-----4.1-----" Disp�o{sal Fiad: Distance from nearest well _''_-Distance from ndafion_46--r------DisfanceJo nearest lot line-____ uq� Number of lines___.. --"---- -"ir--------------Length of each line_- —Width �- of Type of filter material_.(-,,.--- - Depth of filter materia-A?0- -.ota length nth_ AV " -: -- Cesspool: -.---\ Seege Pit: Distance to nearest well r ---- . -Distance fr foundation ___" ___ Number of pits_ __- -_ ��---.Distance to nearest Jot line___.-__-- -------__-"_Lining material_ ____.Size: Diameter_ .01 -- - ��.---- ---.De fin.. � �` � Cess ool: p .ZJ -------------- p Distance from nearest well_"________._.-- Distance from foundation - Lining material-------------------------------------- Privy: _____"---- ' ❑ Size: Diameter---- -------------------- _-------Depth---------------------------------------------------- -------------------- --- Privy: Distance from nearest well_-"---_- -_--.--__ Liquid Capacity----------------------------gals. ----- ___"__--_Distance from nearest buildin ❑ Distance to nearest lot line-------- ---------- - g------------------------------------------ ------------i ----------------•------------ ------------ ------"----- emodeling and/or repairing (describe):------------------- ----------- -------------------------------------------------- cercith -•-----•---------------•-----------------------------•----------•---•------ I hereby I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State I ws, d rul------------------------------------------------ --------- -----------and ua+io lns of the San Joaquin Local Health District. (Signed) r -Tnc-------------- -------SY------------------------------------------- -- i Contract " ;p or] - = --------(Title)---- .�di-ma-ma (Plot plan, showing size of lot, Iota+ion of sys+em in rel n to wells, buil mgs, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY__-"._-_.___.____"- _-- - - -------------- --------------------------- ---------------------REVIEWED BY -gY ------------------------ `f ` DATE ------ -------- - ---------------------------- -- UILDWG PERMIT ISSUEDDATE__- _. -------------------- ---- A terations and/or recommendations:-" ----------- -------•----------------------------------------------- DATE_.---- ------------- -------------- - ----------------------- i: ---------------------- -------------- ----------------- -----------------------------"----------•---•----------•----------------------------------------- - --• ------------ ----------•---------- - ---------------------------------=-- - ------------------ ----------- - -- ---------------------------- ------------------------ --------------------------------- FINAL INSPECTION BY. ----------------------------------------------� Date--. -- -� ---------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreet 300 West Oak Street Stockton, California 132 Sycamore Street 814 Narfh "C" Lodi, Celifornie Street Manteca, California Tracy, California E5-4-2M ro-sz Revised W-glop