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- r y APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) ) �- _ Date Issued 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__= -5_,ZOhJ1Vlt_ rF� ------------------- Owner's Name--------- -`�_IST-INt-------S�_NVo-----•------------• ------------- ------------ ' 4 cc -- --- ---------------------------- Phone-------- -----------------------•- Address--------------%S_RMfr---------------------------------------------------------------------------- --------- - Contractor's Name------�10--- •- ---------------------------------------------------------------- Phone------------•---------------------- Instaliation will serve: Residence [�ApartmenLHouse ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ It Number of living units: ---I---- Number of bedrooms _z__-,Number of baths Lot size ___s} __X__4• ___-_________________ Water Supply: Public system ❑ Community system ❑ .Private Depth to Water Table .1160 ft. _Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay.Loa0E]_Clay ❑ Adobe W Hardpan ❑ Previous Application Made: Yes R�No ❑ New Construction: Yes d No ❑ FHA/VA: Yes ❑ No R TYPE OF INSTALLATION AND SPECIFICATIONS: WE�U.FPrIe- (No septic tank or'cesspool permiffg0jf1public sewer is available within 200 feete) �f Septic Tank: Distance from nearest we l Distance from foundation.___ZO-----_.Mat�efria__ W . -- 4---------- '011P _`-- No. of compartments.--------Z-------------Size---- X_S � Liquid depth--------`f'--------_----Capacity...--f�e�� Dispos Field: Distance from nearest welf__ __._.Distance from foundation__20___.__tDistance to nearest lot)ine____ _..____-. Number of lines____._.- __ --____-__-_Length of each Iine___Z _ 0-.Width of trench-__. . _ rr ,r � r --------------- 'SUMP UMPType of filter material____-_C4[___Depth of filter material----_E- --- -___Total length------_"K�_--_______-_-___--__-_ rwell1 , ';e�e�ser Pit: Distance to nearest _____S-Q. _ ____Distance from foundation___15 ___.Dis#ante tp nearest lot liine____� - _ _____- Number of pits.__._ -__------- Lining material_-_. �'ilK_Size: Diameter____ b X_µ _ 7 ____Depth_ __ _____________________ Cesspool Distance from:,.hearest well-----------------Distance from foundation---- ---------------Lining material-________--_.____________.___________- F ❑ Size: Diameter--------------------------------------Depth--------------------------- Liquid Capacity-.--------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building________________________________--_. ❑ Distance to nearest lot l'ire---------------------------------------------- --------------------------------------------------------------------------------------------- r- Remodeling and/or repairing (describe):-�--- 414CQ------UkftR-r-IL t ------ Qr__�_P R9.tr-----1R�------ 4 f tN1. AT41 Q `Ir' Ti4� N ,ED .D, 1 c.?41ZIt-lk I"s------#aF '-----Pp'-o Phi ----l_V N G a #� - -�T v � ----�a--��._4-p�r�Qa��sK�Q-�--_. ��.----+.�w t � re ��h`a� -Q preepare fhis`gyp TcatiSd and that the work will 6e done in accordance with San Joaquin County ' ordinances, State laws, and rules an regulations of the San Joaquin Loll Health District. Si ned k • -------------------------------------------- ________ __________(Owner and/or Contractor) By:---------------....... ---------------------------------------------------------------------------------------------- (Title)_ (Plot plan, showing size , locationof system in relation to wells, buildings, etc., can.be placed on reverse side). FOR DEPARTMENT USE ONLY . .-. APPLICATION ACCEPTED BY-------------------------------------------- -------------------------------------------------- DATE r- ------------------------ REVIEWED BY------------------------------- -------------------- -------------------------- DAT E- �� BUILDING PERMIT ISSUED------------ ---------- - --------------- DATE------------------------------------------------------------- 4 � Alterationsand/or recommendations:----------------- ----------------------------------------------------------------------------------------------- ------------------------------------------- ------------------•------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------- -------------------------•------------------------------------------------ ------------------------------------------------------------------------- ---------- -- -- --------------------- - ------ ---- ----------------------------------- ---------------- ---- --- --- -------- ---------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- ----------------------------------- - 4 FINAL INSPECTION BY: Date _ ------------------------------------------------------------ SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Ladi,,.California Manteca, California Tracy, California ES-4--2M Revises 1.57 F-P.CO.