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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. This application is made in compliance with County Ordinance No. 549. I yG Z N.4 3S j17 0'/ 1/20-5 4'7'1 'V:2 S JOB ADDRESS AND LOCATION--------•-'--- 64 a--------------)-------------t -- Owher's Name-------------- - Phone -��-1'��-� . �. _ Address--------- ... =---------------- �� -)------(0-•---- - Contractor's Name---------------- -'---•----------------------------------------- ---- ------ Phone----------------------------------- F Installation will serve: Residence �Apartment House ❑ Commercial F1 Trailer Court El Motel ❑ Other E]. � �; __ Numbe�r of living units: __7__ Number of bedrooms __ ___ Number of baths _)-.-__ Lot size ^_______________ _y________ 3Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table -------- ft. t Character.of-soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe 8--T-iardpan ❑ Previous Application Made: Yes ❑ No [r New Construction: Yes B No ❑ FHA/VA: Yes ❑ No [L,—� Ey TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic`tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance.from nearest well__1i+ --Distance from foundation---)_Q____. :__.Material_____ ---------_---________-------------------- ' No. ___ ____..____-_-*No. of,compartments__'_= ---------- -----Size--A:-x-_' --Y--------Liquid depth--- 2/----------------Capacity----RO---------- Disposal Field: Distance from nearest well_7� __Distance .from foundation____ _._______-Distance to nearest lot lir e._ �____-_.- ©/ -'Number of-lines--------�------------ --------Length,ofeach_line-----Y_3-----------------.Width of trench------ �/---------------------- tr-- I- ?/ Type or filter material_____] 0-- ---------Depth of,filter,material___-� ___--______.Total length__-____._-/_io-D-----------_---------- yundation________ 4 ❑a pll__`__________- Distancefrom foundation to nearest lot line ________________ .pe Pit: Distance to nearest we 9 ee: Number of its-----------•---------Lining material-_:"-----------------Si e Diameter------------------____ Depth------------ S Cesspool: Distance from nearest well_---___-_.__.._-Distance from foundation--------------- materia4____-___-_______-___-_____________- J ElSize: Diameter-------------------------------------Depth----------------------------- -------------- ------Liquid Capacity-. ------------------ gals. Privy: Distance from nearest well----_-------_------------------ _________Distance from nearest building----------___________-__--______---_-__.. ❑ Distance to nearest lot 116e--------------- --------- r --------------------------- _ . .__ _ _ _ ----- ---------------------------- Remodeling and/or repairing {describe}-_:_- _ -------------------------------- =------- -=------------- __------ = -------------- -------------------------------------- ----------------------------------------------_________________-------_------------------------------------_-----------------------_--------------------------------_______ ; _____________ ___________________________________________________________________________________________________________________•__________--_--._____-_________-__---_-__-.___.________-______.-------_____.____-__.----_-- 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 re uI fions of the San,Joaquio ai Health District. - - (Owner and/or Contractor) gned . ---- ---------(SiBy:--- --------------------•--------------------------------------------------------------- -----------------------------------(Title)---------------------------•---------------------------------- i (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 APPLICATIONACCEPTED BY__._._. `�-�- -----_-_ --- ---------------------------------------------------------- DATE---------- ----------------------------- REVIEWEDBY------------------------- ---- .. DATE------------ ---------- ------------------------------- BOILDINGPERMIT ISSUED---------------------- --------------------------------•----------- ------------------------------ DATE-----------------------------------------------------•- Alterations and/or recommendations---------------- -- -------------------------------------------------------------------------•-------------------------------•-•---__--------_------------- -------------------------------•----------------------------------------------------------------------------------------------------------------•-------- -------------------------------------------------------------- ----------------------------------------- ----------- ---- ------- _ � 'h- FINAL INSPECTION BY------ ------------- --• ---- ------ Date-_ J6_7 2-1--T� .....------------------------------ 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-9-2M Revised 1-57 F-P.CO.