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r ' APPLICATION FOR SANITATION PERMIT Permit No. 1� (Complete in Duplicate) /// Date Issued .-- l-f3� Applica-�ion is hereby madelfci the San Joaquin Local Health District for a permit o construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND L C�A{{TIO�NJ--- --------- --%✓ _ _.._ 6 fx .. ------------------------------------------- _- Phone_ •--a - --------------- Owner's Nam�1e.�.-�r Address -- -------------------------- ontractor s ame......:....... . _ = ---------------------- ; ..-.. Phone-------_-_---_-----_--------- Installation - •----_-----_-- - - Installation will serve: Residence' Apartment House ❑ Commercial [7] Trailer Court E] Motel C] Other ❑ 4r Number of living units: __ ___ Number of bedrooms _��--- Number of baths .1___ Lot size ------ Water Supply: Public.'ystel Community system El Private E] Depfh to Wafer Table,, Character of soil to a Iepthliof 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe`_)3'Hardpan ❑ Previous Applicafion Made: Yes ❑ 'No New Construction: Yes 1 I/ No 1-1I L T . TYPE OF INSTALLATION AND SPECIFIC TIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) � eptic Tank: Distance' from nearest well-----------------Distance from foundation_--__--------------.Material--_-___-___._-'._._----.------___-_--_---_----_. '►� {� .. C! �i `- No of`�� mo partments -- - Size Liquid depth Capacity----------------------- isposal Feld: Distance=from nearest well---____________-Distance from foundation--------------------Distance to nearest lot line_-_.---..--.___-. [ Number',of lines-----------------------------------Length of each line------------------------___---Width of french----------------------------------- (((,��//�� Type ofifiiter material-------------------------Depth of filter material----------------------- Total length------------------------------------------ '!to Pit: Distantto nearest welll_ 1'_ Distance from foundation---/.!f_.._______.Distance to nearest lot line------ --------- I v 1 Numbed of pits--��---------- Lining material-�„-:�-�___---Sue:'Diameter-------�_�-------------Deptn_________ ,��--�---____-- h ' . Cesspool: - Distant II from nearest well-----------------Distance from foundation____..___..--r-_-_.Lining material----------------- ?. I ❑ Size: Diameter------------------ ------- ----------Depth-----------------------------------------------=----Liquid Capacity----------------------------gals, ' Privy- �!Distance from /1nearest well------------------------------------------------- from nI earest building_._._.____-_____________________ ___________. ❑ Distance to nearest of me------- -------------- -------- Remodein rid/or repairirg3(describe):- c -= . . ------------------------------ ---------------••----•--• ✓ ' #w -- -, --- f� = -- ------------------------ jk------------------ • -- ------ ---•-------•---- --------- ----------------------------------------------- -------------------------------------------------------------------------------------------------------------------------- -------------------------------------------------- I hereby'cert fy that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and d regulations of the San Joaquin Local Health District. (Signed) :' ----------------------------------------------------------------•---------------------------i--------------- -----( / ) Owner and/or Cantractos BY.. lh. ! -------•-------- •-----------------------------------------------------------{Title) = j =�' --r-------------------- ,---------- (Piot plan, showing size'oflldt, location of system in relation to wel[s, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY ` APPLIV WED BY 1 CATION ACCEPTED'.BY--------------------------- DATE-------`f---•----------------------------------------- RE IE -M --------------------------------------------- --- --------- DATE BUILDING PERMIT ISSUEDI� DATE------------- -- ---------••--_------------___-- •--•--- - = Alterations and/or recommendations:---------------------- ------- �------------------------------------------------- �---• ................... ---------------------------- J- ------------ --------- > \ --------------------- - .� -i r7 76 : ---------------------------------------------------------------------------------------------------- I : I FINAL INSPECTION BY: Date-..)-/--r--yS�� --------------------------------------- -- - - i . SAN JOAQUIN LOCAL HEALTH DISTRICT 134 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 W-2100 IM