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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) - T Date Issued _ 6/__3-�X Pi1 Application is hereby made to the San Joaquin Local Health District for a perrimit_to construct and install the work herein described. This application is made in compliance with County -Ordinance N6.`549: \ JOB ADDRESS AND LOCATION.�.1.�,,V1�J -' 17 1 �5'lf---------------------------------------------------------- Owner's Name ----------i Ci! _-ww.��------•--------------------------------------------------------------------- Phone -------------------------------- Address ----------------- -------------------------------Address----------------- lw_'�r = Contractor's Name________________ : Installation will serve: Residence Apartment House ❑ ,'Co-mmercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units .�_!___ Number of bedrooms -_w1... Number of baths __/___ Lot size,_._%_/�-----______________________- Water Supply: Public system' ❑ Community system Private ❑ Depth to Water Table -fe ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel L Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes ❑ No New Constru'ct'ion: Yes ❑ No 2��FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or' cesspool permitted if public sewer is available within 200 feet.) Sceptic Tank: Distance from nearest well ----------------- Distance from foundation __________________.Material-_____._____._.____________---____.___________- r /�'j/ No. of coins artments--------------------------Size----__-_"-------- -_Liquid de #h -------_----.___-_____---_Capacity s Disposal Field: Distance from nearest well _.___'-------- Distance from foundation_____ -------- _Distance to nearest lot line__��--- _. r �< Number of lines______________'r_ --Length of e-64ine_____ .z � Width of trench_._s�r/l_'S_6/_._______________ -- 5� i � A141- Type of filter material_Depth of filter material____ _______ Total length ------- lr�_______________________ i ! o nearest well ___-^"� ___Distance from foundation ---- _______.D's ce to nearest lot line -_o- 4. /�� Number of its._._ _-__-__._______Linin material_ Size: Diameter_-----_ Depth ---- ___ erep E i Distance t r Cesspool: ' Distance from nearest well ----------------- Distance from foundation -------------------- Lining material -------------------------------------- ElSize: Diameter-- -----------------------------' Depth------------------ _ - ------Liquid Capacity--------- :gals. Privy: Distance from nearest well ____-------------- ---------------- Distance from nearest building________________ ----------------------------------------- ❑ Distance to nearest lot line-------------- F ' Remodeling and/or repairing'i(describe)-------------------- ------0MAV _--------- ,-------------------------------------------------------- ------------------------------------------------------------------------------------------- ------------------------- ! -------------------------------------------------------------------------•------------------------------- -----------------------••------ --------------------------------------------------------------------- -------------------------- ------ ---.-- 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 ruulle-s and regulations of the I'San Joaquin Local Health District. (Signed)---------------------- f a_Z-2-----'------------------------------------------------------ _____________________._(Qwrrar--and-/-•or Contractor) By: -----------------------------------------------' e- =----- ±------------------------- -----------------(Title)-- -------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR Dt ARTMENT USE ONLY APPLICATION ACCEPTED BY ---------- -------- DATE ----- �-�----- ------------------- REVIEWEDBY ----------------------------------------------------------- ----------------------------------------------------------------- DATE BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE Alterations and/or recomm ndations-----------------------------------------------------------------•--------------------------------- -•------------------•- ----•-----------------------�y- #7 l ~�`� ` Z` `'r— -------------- •---------------- ---------- -----------------CQ 1V f%j T1-0�---------------D-'--K-------- -------- --R- c:?---------------- -------- ----------------------------------- FINAL INSPECTI =------- ----- --- Date---------- O �r7 SAN JOAQUIN LOCAL HEALTH -DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Sei, 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M Revised 1-57 F.P.CO.