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1 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) -- Date Issued _____ T 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. 544. JOB ADDRESS AND -C--A-/T- - -N-------ead `,- �f---�•- - - - (Y/(/`-/am/-------•--- ----------------------.---e------- --------------------------.------------------------- Owner's Name------------ d ---------- r------7—.. ------- S - 40hone- Address L�r-- •-••------------------------- _ -••-------------------------------- A41 Contractor's Name----------------- 4 16012/ ------------------------- " -- -------- -- -----------------------•--- Phone.--------------------------------- Installation ------- ------••--------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ o Number of living units:!:--/--- Number of bedrooms _- Number. of baths __f__ Lot size Z"-- --**o---------------------- Water _______ _____________Water Supply: Public systemCommunity system ❑ Private ❑- Depth to Water Table Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe hardpan ❑ , .1 Previous Application Made: Yes [] No New Construction: Yes [] No Q--FHA/VA: Yes ❑ No [ ' TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) ,Se tic Tank: Distance from nearest well----- ___Distance from foundation--------------------Material---------------_------._____________-___________ No. of compartments.--- _Sizer-----------------------------Liquid depth--------------------------Capacity----------------------- i Disposal Field: Distance from nearest well �+�---Distance from foundation__dation -Distance to nearest ! line____ __ . Number of lines---------------- - - -- ~x` G� � - _-_- Length of each €ine____��`_-� ____- Width of french------ ----fi_4_-�--------------- ///y// Type of filter material_;� epth of filter material_---.�X�------Total length--'--#00' __ --------______ _______ ee a e Pit: Distance to nearest well------ --------Qistancefr m foundation--------------------Dt�5e to nearest to line_ -- Number of pits_____.--------------Lining material-�_�I --Size: Diameter_ .---------Depth-__- ------------------------ Cesspool: Distance from nearest p o a est well---------- ------Distance from foundation--------------------Lining material______.___-______.__-__________ ❑ Size: Diameter----------------------------------------Depth-----------------_-----------:---------------------Liquid Capacity-.-------------------------ga Privy: Distance rrom nearest well-------------------------------------------------Distance from nearest building______..___-----------_________________._. ❑ Distance to nearest lot line -- ----------------------------------------------------------------------------------------------------------------------- ll - r Remodeling anc�/or repairing;{describe Lel -�'�--------------------------------------•-----------•-----------=----------- -------------------------------------:: ---------------------------------------------------------------------------------------------------- . I 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)------------------------- �1 -- �- �� =' = `` ""„ ` {Owner Rt�}vr Contractor) ------ By:--------------------------------- ----•----------- --- - -------- ----------------------------------(Title)- � ------ ------ (Plot plan, showing size of lot,'location of s m in.relation to wells, buildings, etc., can be placed on reverse side). t 00 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---- ------------------------------------------------------------------------- DATE-------5-` -�------------------------ REVIEWEDBY--------------------------t------------------------------------------------------I------------------------•-------------------- DATE------------------------------------------------------------ BUILDING PERMIT ISSUED-------._.•---------------------------- -------------- -- --- DATE------------------------------------------------------------ - - ------ ----- ---------------- Alterations and/or recommendations--------- ___FX_�J-_-_._-_ _S_____________Q•�{___________ _ T -I© i 'g t-- �= ®� ��- --------------7`,. .® `------------------------------ -------------------------------------------- -------------------------------L ---- ----- -- - ---------------------------------------------------------------------------------------------------- --- ------- - --- - FINAL INSPECT Date --• --- ------------ SAN --------- SAN JOAQUIN 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 y P' ES-4-2M Revised 1-57 F.P.Co.