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.J�,`� � T V I APPLICATION FOR SANITATION PERMIT Permit No: .-____- ' (Complete in Duplicate) Date Issued --------!3F 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 LOCATION------- 79F%�----•----�� ------ r�-� �'.. �}• Owner's Name------------- c -,c--------- Address---- _4�1$ ---------- � - - ------------------------- Contractor's Name----------•__ r::.-_C��_---- ---- �.�__-- __ __ - --------------------- Phone _ r Installation will serve: Residence L�f Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living unifis: ___ Number"of bedrooms ___ Number of baths f�-. Lot size _ � __f__________________ Wafer Supply: Public system K Community system ❑ Private ❑ Depth to Water Table;,4C?_ ft.. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeX Hardpan ❑ Previous Application Made: Yes ❑ No Ff. New Construction: Yes ❑ 'No X FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: No septic tank or`cesspool permitted if public sewer is available within 200 feet.) S is ank: Distance from nearest well------------- Distance from foundation--------------------Material__-________.__________.__________--_--._._-____. No. of compartments------------------------ -Size---- Liquid depth-------------------------Capacity----------•------•---- -f _r of spo I Field: Distance from nearest well---�.WA''Distance from foundation----�S__..-_.Distance to nearest lot line---- __.____... f Number of lines_______ -------------_---------Length of each line-----_�TQ_:n-e _.Width of trench----- �` Type of filter material:_=__Po{X._.__Depth of filter material___.. ........Total length------------ __________________- Seepage Pit: Distance to nearest welL__ Q_A/i___Distance from fon ation____ 7._.___.Distan`/to nearest lot Number of pits------- -----------Lining material-_- __.Size: Diameter____ ._.-------Depth..__..FP `___-________ Cesspool: Distance from nearest well________________Distance from foundation--------------------Lining material-___._____________________.____--_-. ❑ Size: Diameter-------------------------------------Depth----------------------- ----------------------Liquid Capacity--- -------gals. Privy: Distance from nearest well ______----------- ------------------------------Distance from nearesf building------------------------------------------ ElDistance to nearest lot lire------------------------------- -------------------------------------------•------------------------------------------- ------ ------------- Remodeling and/or repairing (describe)' C/ --- C�C:'�tif- -- ------- -----•--....• ..__. --------------------- `------- - ---••---= ---••------------------------------------------------ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State law nd rules and regulations of the San Joaquin Local Health District. (Signed)--------------- --------`'G ----L`---------------------------------------- ------------- (Owner and/or Contractor) By--------------------- �- i� - - - - - •---------------- --(Title)------ (Plot plan, showing size of lot, location of sys in relafion to well's, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- -•- ------------------------- -------------------------------------------------------- DATE-�------------------------------- ------------------ REVIEWED BY--------------------------------- -- ------------------------------------------------------------------------------------- DATE---sx BUILDING PERMIT ISSUED------------------------------------------------------------------------------------------------------ DATE-------�i----------- Alterations and/or recommendations---------------------------------------••------------••---•---• -----------------------------------------------------. ----------- ------------- --------- ---- ---- ---------4• ----4--- "�' ! 1 - !--------. --- e. r_. - x - ---------------------- -- ----------------------------- --------------------------------'% ` : ---------------------------------------------------------------- 21 — FINAL INSPECTION BY:.-- Date--1' ---• --------------------�� SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes} oak Streef 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1-57 F.P.CO.