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,1 APPLICATION FOR SANITATION PERMIT Permit No. __f3... ........... (Complete in Duplicate) Date IssuedS.�_ 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 - - ------- P e -- - _ hon - - =-----lam Owners Name-- -----------------' d ----------------- -- ------- Address--- -.------------------------------ --- ------------•--- Phone _.._ Contractor's Name--------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _4 Number of bedrooms /_--- Number of baths ___/--- Lot size _''__//_. ___ Water Supply: Public system Community system ❑ Private ❑ .Depth to Water Table VP- ft. rs ""'•.. _. -�- Adobe ardpan Character of soil to a depth'of 3 feet: Sand El Gravel El (Sandy Loam El Clay Loam ❑ Clay El �� ❑ Previous Application Made: Yes El No P---New Construction.,Yes ElNo I HA/VA: Yes ❑ No [e # TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if`public sewer is available within 200 feet.) nearest well ------------------------------Distance from.foundation__________________.Material_________-____-_ ti ank: Distance from, No. of compartments---------- -----------size----=---------------------------Liquid depth--------------------------Capacity----------------------- pisposal Field: Distance from nearest well .=-Distance)from foundation__ -_______Distance #o nearest to line_ ----- Disposal ____- ^ /f Number of lines------ ----------`---- -----A-Length of each line-------s- --------Width of trench-----�_-__--------------•-- L�Y ,may- Type of filter material__�t__9�"#7�-A-Depth of filter material----- length____'_.___�___�_____________�---- � �/Pit: D stance to nearest well__ __ stancfm Die r foundation___--d_:.-_..D�3�� to nearest lot line___ ----: Seepage • ( I //jj `` ,,�� Number of pits �� Lining material- -'.Size: Diameter-----3a----- Depth-._��'� Cesspool: Distance from nearest well'--------------Distance from.foundation____._._--___._,___.Lining material------ --gals. ❑ Size: Diameter I ----------Dept h_,-----------------`----------------------------Liquid Capacity------------------------•-- Distance:from nearest building Privy: Distance from nearest well- ---------:_------ :----------- ❑ Distance to nearest lot line ----- +----------------------------------------------- -----•---- Remodeling and/or repairing (describe)------------ -------------`--------------------------- ----- ------------------------------------------- R ________________________________________________________________ ._- ____... i ¢ ________---------------------------------------____--______________._-_____-______________.•_________.__-___._.-____-___________.______________.________________ ------------------------------- ----------------- herebyPfe that I have preparedthis as olf the San JoaquinhLocalkHealltheDistrictn accordance with San Joaquin County ordinances, Sws, and rules 'and reg " Contractor) -- ran ---- _ [Owner and/or Co or (Signed)-- --- ---- ----------------------------------- By------- ------------------------ ---:-�Al-107- ---------•---------------•------•--------(Title)--- - s i (Plot plan, showing size of lot, location system in,relati&i to,wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY DATE—----------t ----------------•----------- DATE �I REVIEWEDBY -------------------------------------=------ BUILDING PERMIT ISSUED --- ---=------- --- ------------- ---------------------- DATE a - - Alterations and/or recommendations---------------- ----- 2 --------------------- ------------ --------------------------------------------------- --•------•------- •------- 5 ----------------------- - •---------------------Da- -------------------- - - FINAL INSPECTION BY::_ -- -. - _ 171 f--- 7------ SAN JO QUIN LOCAL HEALTH DISTRICT 132 S camore Street 814 North "C" Street 130 South American Scree+ 300 West Oak Street y Tracy, California Stockton, California Lodi, California Manteca, California y. ES-9-2M I Revised 1-57 F.P.CO.