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APPLICATION FOR SANITATION PERMIT Permit -,.(Complete in Duplicate} 4- Date Issued ------- ------ Application is hereby made to the Sari Joaquin Local Health-District for a permit to construct and install the or qr escril644- This application is made in compliance with County Ordinance No. 549. --- ------- --------- JOB ADDRESS AND LOCATION....j- --------------------- ---- ----- Owner's Name-----[ 1j__1--- YL ho, ---- ------- e------------------------------------ A .............. ------------------------- ---------- Address---------S_Le!.�... ----------9_7�4-= Contractor's Name----g_C_ �-------+---- ---------------------------------------------------------------- Phone-------- -------------------------- Installation will serve: Residence �Apartment House ❑ Commercial E] 'Trailer Court 0 Motel E]. Other E] Number of living units: Number of bedrooms -Y'_ Number of baths I----- Lot size ---------------------- Water Supply: -Public system E] Community system F1' PrivateDepth to Water Table -------- ft. Character of soil to a depfh of 3 feet: Sand [] Gravel 0 Sandy Loam El Clay Loam El Clay E-] Adobe D& Hardpan Previous Application Made: Yes E] No New Construction: Yes g, No E] FHA/VA.. Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within_200feet.) Septic Tank: Distance from nearest well-cS-O--------Distance from foundafion-J-0---------- Mat rial---2_2�_on�------------ No. of compartments-----140;--------------- Liquid depth----- ---------__----Ca acit Disposal Field: Distance from nearest'welI'.._.S_b___ from founclafion-J-10---—---Distance to nearest lot I e__��-------- -_ir Number of lines------ ------- ____L th of each line----ig 40--- ---�____.Wiclfh of trench----af---------------------- T Type of Pilfer material 4xatpr'material------12 ______Total length----1-4-ro------------------------ Seepage Pit: Distance to nearest well----------�Distance from foundation-------------------L.Distance to nearest lot line__________-______ ❑ ine----------------- El Number of pits------- -------------Lining-material-----------------------Size: Diameter-------------- ---------Depth---------r------------------------ Cesspool: Distance from nearest well-----------------Distance.from foundafion----------- _-.__-.Lining material----------------------------------- El Size: Diameter----- ---------------;------------Depth_----------------------------------------------------Liqu;d Capacity--r------------------------gal Privy: Distance from nearest well------------------------------------------------Distance from nearest building----_---__.____________--____.___.___-- ElDistance to nearest lot lire--.---'---- ------- - ------------------------------------------------I----------------------------------------------------------------- -- Remodeling and/or repairing (describe)---------I— ------ ----------------------------------------------------------- --------------------------------------I----------11-------- ----------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------:-------------------------------------------------------- ----------------------------------------------------------------------- -----------------------------------------------------------------------------------I-------------------------------------------------------------------------------------------------------- ------------------------------ I hereby certify that I have prepared this application and that tWwork will be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations of the San Joaq6in Local Health District. (Signed) I —I ---------------------- --- -------- - -------------------------------I-,------------------ -------------------------------------------------------------------(Own.er and/or Contractor) By:----- A--- - ------ - - ------ --- - -------------Z----------------------------(Tif le)-----k----------------------------------------------------------- tAl C i6i -placed on reverse side). (Plot plan, showing size 0 system in relation to wells, buildings, etc., can beL FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY - ------------ ----------- •------------------------ DATE_-- ' -- --------------------------------- REVIEWEDBY--------------------------------------------- ------- ---------- -- ---- ---------------- DATE I ------------------------ ----------------------- BUILDING PERMIT ISSUED---------------------- --------- ----------------------------------------------- DATE------ --- ------ Alterations and/or recommendations-------------- --------- - ---------------------------------------------------------------------- --------- -------4-;r - --------------------------------------------------------------------------------------------------------------------------------------------------------------- ---- --- --------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------- ------------------- --------------------------------------------------------------------------------------------------------------------------------------------------------------------- ------------------------------------- - ------------------------------------------------------------------------------------ - ------------------- ---------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY:- --------------- ------ -- --------- Date------- -----------------------------I SAN JOAQUIN LOCA EALTH DISTRICT 110 South American Stroof 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M Reviseci 1-57 F.P120.