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4 APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) tD�ate Issued 46K ---. Application is hereby made,to the San�Joaquin`Local Health District for a permit to construct and install the work herein described. This applicatiori is made in compliance.with-County Ordinan e No. S49. 17 JOB ADDRESS A D j OCATIO __- � - -_ __-------------- _f _ _ 1 _ Owner's Name ____ __'=_ __ ------ - - - - -ff _ --------------------------------------- Contractor's ----- - Phone ------------------------------------ ----------- Address --:------- : Address--------------------- ----------------------------------------- = r ContractorsName--- ------ - ------------------------ - -------------- -------------------------------•----- Phone----------------------------------- Installation will serve: . Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ M J,7l ❑ Other Number of living units: ___ ___ umber of bedrooms _Z__ Number of baths __f-____ Lot size Water Supply: ' Public system Community system ❑ Private ❑ Depth to Water Table --------- ft. Character of soil to a depth"o0.f� feet Sand. Gravel ❑ Sandy Loam Clay Loam E] Clays❑r,;Adobe Hardpan C]Previous Application Made:..Yes,E New.Construction: Yes o ❑ FHA/VA: Yes ❑ `.No TYPE OF INSTALLATION AND SPECIFICATIONS: f i {No septic tank or'cesspool permitted.'f public se er..is.available within 200 feet.} ' { �J�stanc fro foun tionW/P- -.- Septic nk: Distance from nearest we --- _ ;F D' _ Materi _ No. of comp#artments-µ--- '---- - ize--- Liquid depth--- ---------t" --_--- CapacitY-- f - Disposa.Field: Distance-from nearest well___ __ Distance from foundation _ _ -- _ Distanc to nearest lot line___ Number of lines___-- -___ Length of e'�ch line____________ _ _ Width of trench__.__ �i. `T Type of filtJ-materi 11_6L IJ epth-of•filter-mate ria l___._=l_ _ ______:_.Total length----------l__-C2_�------------------ Seepage Pit:-.' N Distance.to nearest well___:_:__ _" Distancleklfromfoundation-------------4.__:.Distance to nearest lot line--."------------- ❑ Number:of pits,_- "_________Lining, material---------------!-,---.--Size: Diameter-----------------------Depth--------------------------------- Cesspool: Distance' from near est"well-------------------Distance from foundation .___.Lining material--------------------------- --------- a Size: Diameter_ --r-- -------------------D'epFh'"""" " ------------------- Liquid Capacity als, i p Y g y F Distance to nearest lot line----�- -- '�-------.- g---------------------------"------------ Distance from nearest building Priv Distance from nearest well-----------------------------------------tom ` Remodeling and/or re:fairing (describe):----------------------- I.------..� =------------------------------------------------------ -----------------------------------•----_-_- ----------------- ------------------- -------- ------------------------. -------- ---- - I hereby certify that l have prepared this application and that the work will-be done in accordance with San Joaquin County ordinances, State laws, and rules and regulations o the San Joaquin Local He/alfh District. (Signed '- ! - r//� til" --- ----------- - ---- - _______________________________{Owner and/or Contractor1 t BY: -- -=--------------- - -----_-- ------------------- ----------------------(Title)--------------------------------------------------------------- (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). f FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------.-s . ---------------- - ' .::.____ -----------::---:- --- DATEt5 --------------------------------------------------- -REVIEWED BY-------------------- - " ° ------ -------------------------------------------------------- DATE_- ----------------------- BUILDING PERMIT ISSUED. ..------------------------- ----------------------------------------- ------------------------ DATE_- `'Ft"------------------ ------ ----------- Alterations and/or recommendations:---' ---------- - ------------------------------------------- ---------------�----------------- A �---- ...- `-�- . . , z ------------------------------------------"------------- ••----------------- ---------------------------- -•--------------------- ---------------- { " . 1 = ------------------------- ---- - --------------------------- FINAL INSPECTION BY:_y - ----x_ ". t Qate _ •'� - -------"--------------------- 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 t. Tracy, California ES--9---2M , Revises 1.57 FY-CO.