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i 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. in compliance with County Ordinance No. 549.€ This application is made 1 { Alf 4 r - r _� - j u � --- JOB ADDRESS AND LOCATIONw Phone Owners Name---_ - .�� --------- . .Yr_ - ----- •----- ----------------------------------------------------- Address ---•-------- ••-----•-----•------•------- ---•-- Phone---•--••-----=----------•---------• Contractors Name ---= --- w : , -- --------•--- --------- -------------------- a e # .+ ' � � Motel Other ❑ z Apartment House ❑ Commercial Trailer Court ❑ ❑ 1. Installation will serve: Residence ❑ p A . 1--.4 . p 0 4/Lr f1 ----- Number of living units: sZ__-_ Number of bedrooms *_ Number of baths ..........r o?size -------------- ----- 4 , �,�./0- Y 0' • De th'to_Water Table t/-- ft. " Water Supply: Public system E Commuriity system-❑ "Private❑, p 5 , ` Adobe . Hardpan ❑ Character of soil to a depth of 3 feet:; Sand ❑ , Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ { Previous Application Made: Yes El F]No. New Construction: Yes. '] No ❑r FHA/VA: Yes E] No El TYPE e AND SPECIFICATIONS: Ou (NINSTALLATION septictankr' polpifblic.sewer is available within 200 feet.) ' Septic Tank: Distance from nearest' resttell - Distance from foundon_,_jfl_______ Material___-____#_,_--__ No. of compartments--------------------- b Size__0 -_X---Liquid.depth----�----------------Capacity.-_I-�-- Disposal Field: Distance 'from near est well' ---t Distance from foundation---)�_____i------Distance to nearest lot line__o _______.- ..... Number of lines______-'"'------------ - Len th of each line___.._-®--- -----Width of trench_ ____-_ _`(____----------------••- 9 Type of filter material_=�`a�P-- '`---+Depth of filter material___-:)_ - ------Total length__ -4y---------------- 4, + ' ^' g s__.__.Distance to nearest lot line_________________ Number of pits---------------.-I-,----Linin material-------------- ------.Size: Diameter-----------------------Depth Seepage Pit: Distance,to'nearest well_.________, _Distance from oun a ion___.:- Cesspool: Distance from nearest-well______________Distance from foundation---------------------Lining material------------------------------------I_ Li -Liquid Capacity gals. Depth q P Size: Diameter----------------------------- r` p a ----------- - -- -� Distance from nearest well k _-Distance from nearest building _ Privy: _ a _ .c . ------------- ID Distance-to nearest !o#'line"r"'--""�-�-=--"= ------- - } t I i x i ' Remodeling and/or repairing (describe):---"------------- ------------------------------_------------------ -° - --•-----------------•----- h -------•-------- ---- - -T - ------ i -----------'-------------------------------'---------------------------•-------------•----'-------------•---•-----'--------- ---_-- ----------------.--._:.. - ------.. ------------------ I hereby certify that I-have prepared this application and that the work will be done`in accordance with San Joaquin County ordinances, S to laws, and rules and re ulations of-the San Joaquin Local Health District. i t =. (Ow Contractor) (Owner and/or t or) . • _v = {Signed) • I B �--- ---------------••-------------------------------- -------------- -------- -------- -------- -------------------------------------c. (Title) c d e_ (Plot p1a�, showing-size of lot, location of system in relalion'to wells, buildings, etc., can be placed on reverse side. * FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY_� ' _ =------------ -----------•' °--------------- DATE_ '_�`_1_'` ---------------------------- REVIEWED By----------------------•---- ----------------r-------- -------- ------ ------ -- ------------- ----- DATE--------------------------------- ----------------------------- ISSUE _____•.--------- BUILDING PERMIT ------------------------------------------------ DATE------------------------ -----------------------•------ --- Alterations and/or recommendations------------------------------------------------------------------ -------- --------------- -------------•-------- ---- R -•------- ----- 1 -- --__ -------- - 5 P FINAL INSPECTION BY:__ SAN JOAQUIN LOCAL HEALTH DISTRICT 132 5 camore Street 814 North "C" Street 130 South American Street 300 West Oak Street y Tracy, California Stockton, California Lodi, California Manteca, California S f ES-9-2M ' Revised 1.57 FY.CO.