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t rA APPLICATION FOR SANITATION PERMIT Permit-No. j (Complete in Duplwate) ' .t``. Date Issued Application is hereby made to the San Joaquin Local Health Distric for a permii to construct and install the work herein described. ' elol�This application is madsin compliance with County Ordinance N 549, JOB ADDRESS AN CATION., - -,r . - ----- -._ -. .... __. Owner's Name.... tie z ---• .... •--- ._ � • _._�. .., ..._.,._M._. Phone. Address_ la - __....._ .. ._........' . Contractor's Name..._ _ ..-- -- !U'::_ � - ... Phone. ._._.._. Installation will serve: residence Ap tment House ❑ Commercial ❑ Trailer Cour+ ❑ Motel Other ❑ _. 1 Number of living units: _ ..__ Number of bedrooms.F_.-Number.of baths_.1... Lot size--_ � ._.._-----.-- Water Supply:Public system Community system ❑ Private ❑ Depth ffo Wafer Tahla_!�7 ft, k Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam'E] Clary Loam [] Clay❑ ,Adobes Hardpan ❑ i Previous Application Made: Yes"71 No ❑ New Construction: Yes {( No ❑ FHA/VA Yes ❑ No X_ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 4100) ! Septic Tank. Distance from nearest weV_ -'.Distancefromfo undatron..-.y�_..___ Mast rt�l �•_. � {. No. of compartments-.-,?- ........Size-.��__,�-�..--------Liquid depth-.,.?/.. ._`_Capacity....XQ.�-�--- Disposal Fie d: Distance from nearest well _-Distance from foundation../ s D►stance•-F nearest lot line Number of lines........I._._ .. r M ' _ ........ . Length of each Type of filter material .... Depth of filter materraL__.. ... Total Ion h_.__.... � ... ..........._ Seeps a Pit: Distance to nearest "eller- .....Distance from f ndationC_.A < Die#a e+o nearest tot Number of pits--) __._,__._Lining material. -.--Size: Diameter Cesspool: Distance from nearest well...... ---:_ Distance from foundation + Linin maPerial ......................_._......... ❑ r Size: Diameter_. ...._ ._.......Depth__..... z _ __�.._..Gqui� Ca city gals. Privy: "y"""Drstance from nearest well-------..................:.-_'� ._.__._.._Disiance`flom nearest bui ding...____ __._._..W. ❑ Distance to nearest lot line..._..._.............. 1 -....•...---..__. .......... __...._.._ Remodeling and' or repairing/ airin describe • ..__.___ + P 9 ( f i .. Y ----•---•- ......_. -----...__� .....w:.............. _... .:-- _ ...:..." ..... ._ ___ _��t�---------•-•-�- � •--•- ---•- --.._... ._R............. . - I hereby certify+hat I have pre ared this ap Iicafio and t t,fhe work will be done in accordalce with San Joaquin County ordinance to la" d r a rI` r gula+i f th an J rquin AHhistrict, (Signed). -_.(Own and/or Contractor] By:..-.....-- - - - ':..- (Title]: (Plot plan, showing Y of ocatio "of system in refatien to wells, buildings, etc., can bep ed o rev se de). �. FOR DEPARTMENT USE ONLY _. _.. --------------------------------- •------ DATE_.- � ��-----.---------------------- REVIEWED BY - --=-..__.-..-.__........ - - - - -----------._ APPLICATION ACCEPTED BYDATE _ - ,........._ BUILDING PERMIT ISSUED_. .._._......_......- .__. w .........,.. .._... DATE-..---.I __._. ............ � Alterations and/or nd/orf2r!ec_orn en,d.atons , , ... .. -•- ...... - , ..._..................- -- _ . ....._...: -- --------- .._ l__ -- •.......*..............^.... ------........ .�....�. _.. J..: FINAL INSPECTION' BY:... -------------- v Date- -----------_-_-- - - ...........---...... ,,,.-.....w SAN JOAQUIN LOCAL EALTH DISTRICT 130 South Americon Street. 300 West Oak Street 132 Sycamore Street 814 North "C" Sireet t Stockton, Califonrio Lodi, California Manteca, California Tracy, California ES-4-2M . Revised 1.57 F.P.CO. 1 ti :t