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1 � APPLICATION FOR SANITATION PERMIT Permit No. .._ �'_.1-_ (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 applicafion is made in compliance with County Ordinance No. 544. JOB ADDRESS AND LOCATION_ ____ Owner's Name----- ------------------------------------------------------ - - -- -------------------------------------- -------- ----- Phone------- - ------=-----•------- ----- -------------------------- Address------ --------- --- -------------------------------------------- ' 0_ Installation will serve: Residence— �A artmen t�� - --- - ------ -- ----- - ------- Phone------------ --------------- ----- ---------------------- - p t House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ .__ Number of bedrooms _.:2— Number of baths ,�__ Lot size _ � ' ---- -- -------------- -- - ----------------------- Wafer Supply: Public system ❑ Community system ❑ Privafe yg-'bepth to Water Table'? —it. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan E]Previous Application Made: Yes ElNo 1Vo New Construction: Yes j- ❑ PHA/VA: Yes WR-"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_ /� o it____ Liquid depth __- Distance f om /_ foundation_____ 0_-_._..Material__--6-��-__- - [� No, of compartments-.__-_1�..-__---___---Size � ��p_--• _ _ f ---------Capacity------ .. ..... Disposal Field: Distance from nearest well.. ------Distance from foundation--_( .___.Distance to nearest lot line ---- Number of lines........ . -Len th of each line_____ ___ __ g -------------.Width of french.--- -- oe _ ------------ -4 _______ Type of filter material/ ___0.--------_ Depth of filter material------��----Total length--------- ` Seepage Pit: Distance to nearesf well----//t7------Distance f om f ndation------_ma�yy ~_"+ .Distance to nearest lot line_ __'_--_--- r Number of pits-------.+ .._____Lining material_ ----_Size; Diameter-_ t --- -- � - Depth- -.A_19-------------- Cesspool: Distance from nearest well-_---___-_-_--__Distance from foundation--------------------Lining material-----------___._.._.__--------_--- ❑ Size: Diameter-- ---------De th--------------- Liquid Capacity Cn . p --------"gals. 1 Privy: Distance from nearest wellDistance from nearest building 1 --------- g----------------------------------------- ❑ Distance to nearest lot line______ _____.____-_._._ ---------------------•------------------------------- Remodelingand/or repairing (describe)------------------ �-- 531 Or ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ! hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulafions of the San Joaquin Local Health District. (Signed)_ ✓ � �� -------------------- -------------------------- _ __ _ By:-------------------------------- -------- (Title) / r Contractor] - --- - ------------ ---- .------ ( P g -- ---------- P of Ian, showing size of lot, location of em in.relafion to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------- ------ ----------- // - -------------- ----------------- DATE- ------- [z__-'--- ---_--`�� -------- VIEWED BY------ --------------------------- ----- - --------- - --------- -----------• ------------ - ----- DATE--------------------- BUILDING PERMIT ISSUED------------------ ------- --------------------------- Alterations and/or recommendations: T ------------------------------------------------------------ ;� ----------- _z/- - - ------------------------------------- - FINAL INSPECTION BY:---- Date 6—� - Q ------------------- SAN JOA UIN 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 ERCO. R ' i