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• 4� APPLICATION FOR SANITATION PERMIT Permit No_ __________ II Iy'� i (Complete in Duplicate) Y 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 CATION____ 3 r � Owners Name-------------- - ------ '�GtY1 L�rY --------=--_-----_-_._---=---_--- ------------ --------------- Phone--1Y- ----- - .._�_ ------------------------ Address----------- --------- { l ------N'-------� ` ------------------------------------------------ Contractor's Name-----------------1'----------------------------------------------- --------- ---------------------------------------------- ------------------ Phone----•----------------------------- installation will serve: Residence Z?;j"Apartment House ❑ C.ommercial ❑ Trainer Court ❑ Motel E] Other E]Number of living unitsq___.__ Number of bedrooms __ Number kof baths --------- Lot size ___6'S__?C-- S ------------------------------------ Water Supply: Public systern Community 'system ❑ Private ❑ Depth to Wafer Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe EKAardpan ❑ Previous Application Made: Yes ElNo New Construction:`, e o E] PHA/VA: Yes E] No ^ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available-within 200 feet.)(j Septic jp4 Distance from neareEA wel _-_Distance from fo ndation__-_ _________.Material----- �_� -------------- No. of compartments? ----------Size-----�x---------- --Liquid depth----- /-----------------CapacitY----- ------- is / S ._. Disposal .ieid: Distance from nearest'well Orly-_ Distance from foundation___1_�----.----Distance to nearest lot line_________________ Number of lines________ ___________Lengthth of each line--------- � Width of te moff'lter mater ial-___ Q�c . ------------Total lengt ----- , Seepage Pit: Distance'.to nearest well_____________________ Distance from foundation_----________-------Distance to nearest lot line._____________-__ ❑ `Number of pits----------------------Lining material----_------------------Size: biameter-----------------------Dept h--------------------------------- Cesspool: Distance;'from nearest well-----------------Distance from foundation-------------- -----Lining material_------------------------------------- ❑ Size: Diameter--------------------------------------Depth-----------------------------------------------4----Liquid Capacity--- ------------------------gals. Privy: Distance from nearest well-------------------------------------------------Distance from nearest building_____...___________________________- - . .. ❑ Distance to nearest lot line----------------------------------------------------------------------------------------------------------------------------------------- Remodeling and/or repairing (describe) }' ------- -------------- a: ' li � ' ------------------------------------------•------- '-----------------------------._.-.-.-------------------------------- - I r. ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ I ------------------------------------------------------------ I hereby certif 'hat I hU--nO d this application and that the work will be done in accordance with San Joaquin County ordinances,, State a gulations of the San Joaquin Local Health District. (Signed)- --- --- ` = (Owner and/or Contractor) r 4 By:--------------------------------'----------------------------------------------------------------------- - --------------------------(Title)-------------------------------------------------------------- (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). !� FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------ - - -�------------------------ ---------------------------------------- DATE----W-Aall-s- ------------------------------ REVIEWEDBY •----------:----------------------=�--------------------------- ---------------------------------------------------------- DATE -- ----------- S BUILDINGPERMIT ISSUED------------------------------------------------------------------- ---------------------------------- DATE.------------------------------------------------------------ Alterations and/or recommendations-------------------------------------------------------- ----------------------------- •----------•------------------ ------------ --------- --- I -------------- ------------------------------------------------=--------------------------------------------------------------------------------------------------------=------------------------------------------------------------------- l"V ------ � C7 FINAL fNSP -CTION BY:. f = = -------- -- Date-__- ---1-------------------------------- ----- ------------------------ 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 ES-4-2M Revised 1.57 F.P.CO.