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any APPLICATION FOR SANITATION PERMIT Permit No. f (Complete in Duplicate) Date Issued Applica{ion 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. ( 3 n/, S r�!GCa4 r r2"to JOB ADRESS AND LOCATION 3 yQ- -.x _---------------••-----------------``{� � 3�F0 I ..C)_Owners Name------- --•- --d---- •-•- - ------------ ••---------•• --------------------- ------------------------------------------- Phone---------•-••-------_.._-------•---- Ad res - -----------•------------------------------------------------------------------------ Contractor's ame------G ��_. ___ _ -- Phone---------------------------------- Installation ________________________________Installation will serve: Residence`s Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [_1 Other�❑ Number of living units: _I:__- Number of bedrooms _/----- Number of baths _____I Lot size --- Q----r _.___---------"-----___f______-___ Water Supply: Public system ❑ Community system ❑ Private ' Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loam ❑ Clay ❑ Adobe Hardpan E) \Ltyrevious Application Made: Yes ❑ Nd 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-----J__-_-_ No. of compartments-- ........... Liquid depth_------- Capacity___ _ _____ pisposa Field: Distance from nearest well___��.___Distance from foundation_____�----------Distance to nearest lot iineSS.___�__.__. Width of trench__ Number of lines--_-__-- __-- aL th f each line._ _-./- - ---------- __. Type of filter material_ _�d�+_-�I �cfrlter material _!}_-____.Total length_-_1! _________________________ Q Seepage Pit: Distance to nearest well_______________Distance from foundation--------------------Distance to nearest lot line______--___-__-__ ❑ Number of pits----------------------Liriing material-----------------------Size: Diameter---------- ------------Depth-------------------------------- Cesspool: Distance from nearest well---_-------------Distance from foundation--------------------Lining material------------_._-________.________--__. 1 ❑ Size: Diameter------- ---- ---- -------------------Depth----------------------------------------------------Liquid Capacity- --------------------------gals. 1 Privy: Distance from nearest well------------------ --------.-------------Distance from nearest building.-_______-___-:______________-__--____--- ❑ Distance to nearest lot line-------------- _--------------------------•---------------------- ---------------------------------------- ----------•-- ------------ Remodeling and/or repairing (describe]:__--/-( --� ± ..---- -- ----- -- ---- -----------...--•-•------•.---•-- '�`�- `� = ---------- ----- -----------•---••------•--•-------•--••-------------•--•-------------••---------------------------------------- -------------------------------------------------------------------------------------------------------- i L•., - ----------------• ---------------•-----------------------•------------•-•-------------------------------•------- - --- - --- --------------------------- --- I 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 regulations of the San Joaquin Local Health District. ' (Signed)----- t Y�•c-�L. — - ------------------ -----------------------------------------------------------------------------------(Qwner and/or Contractor) S�Y�S-•---------- -----------------•---- -- F---------------------------------------------------------------------------------(Title)---------- -----------•`-------------------------------------- (Plot pla , showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). } FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY--------------- --- ---- --------------------------------•--------------------- DATE------ - -------_-----------------•-------------------- REVIEWEDBY--------------------------------------------- ------- ---- - -----------------------------------------------------•-- ----- DATE-- BUILDING PERMIT ISSUED------------- ------------ ------ - V DATE--------- I----- -- ------- - ---- - --- ----------------------------------------------------- Alterations and/or recommendafions:--------:-------- ---- ---------------------------•------------------------------------------ -------------I -------- -! = --------------------•------------- ---------- --------------------------------- -------------------------- -------------------•-------------------- - --•-•--- ---------------------- ---------------------------------------------••-------•-- ________________________ -. FINAL INSPECTION BY------------ ---------- -------------------------------------- Date--- --- --- SAN JOAQUIN LOCAL HEALTH DISTRICT f 130 South American Street 300 West Oak Street 132 Sycamore Sfreef 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E -9-2M 145446 ATWOOO 12.54 '