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/_� - ^3 12y v./ 5 APPLICATION FOR SANITATION PERMIT Permit No. ._.��Q.:SJ (Complete in Duplicate) s Date Issued Application is hereby made to the San quin 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. JOS ADDRESS AN LO ATION - / �- '� Owner's Nam ------- -- =----- - - Phones Address------- ------- • • ------------- ---------------------.....-------------------------------------------------------------------------------------•------------ ----- Confractor's Name------ - ----- ------- Phone 6---�` "------- Installation will serve: Residence artment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ---.4_ Number of.bedrooms -------- Number of baths I____ Lot size ..... _fl�__.�___�.�---------1___1__1.1_ a Water Supply: Public system Community system [I private ❑ Depth to Water Table D ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe ardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic '� Distance from nearest well-----------------Distance from foundation--------------------Material------------------------------------------------ No. of compartments--------------------------Size--------------------------------Liquid depth--------------------------Capacity-----------------------v Disposal Field: Distance from nearest welir!'WTt _Distance from foundation-BLS-----____.Distance to nearest lot lin,_!__C7_____.__.� Number of.lines-------1________ ______ Length of each line___: _______ _._.Width of trench.... __ _________..._______. Type of filter material�_�_____Depth of filter material-----/__�_""-------Total' length------a� .. ---------- � Seepage Pit: Distance to nearest well_ a9.-----Distance fr m fou dation_,.-_____-__ Distance to nearest I t lin -_.._ CN 4C�L5 Number of pits-----f--------------Lining mate rial�j,_ .Size: Diameter__. ___..______.___.Deptn_____ ----._______-"---_-._ Cesspool: D•stance from nearest well-----------------Distance from fou ndation-----.--------------Lining material______________.________________--__ ❑ p 7 ---- --------- -----Liquid Capacity_ _----------------`_--gals. Size: Diameter1111---- ----------111111 11---------De Depth ---------------1111-- t ti Privy: Distance from nearest well----------------------------- ---------------------Distance from nearest building__________________________________________ ❑ Distance to nearest lot line-------------------------- ------ ----------------------------- --------------------------------------------------------- ------------- -- - Remodeling and/or repairing (describe):_._._ - - -- --------•---------- -- ------------------------------ ---------------I------------------------------------- -•-----•------------------•-•----•-••-------------•------------------- ------------------------------------------------------- -------------------------------------- ? ------------------------------ -----------"-------------------------------------------"----------------------------------------------------------------------------- ----- --- - 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 regulations of the San Joaquin Local Health District.- ---------------------------------------------------------------- -Owner nd or Contractor (Signed) ----------- P� $ ,1_ _ / ) -------------------------------------------------------•----------------- --- s By�-_--- [Title) (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 BA- ------------------f--Y -------------------------------------------------------------- DATE --____--------------- -------------------------------- REVIEWEDSY--------------------------- --------------- DATE--- --------------- --------------------------1111-- BUiLDING PERMIT ISSUED ---------------------------------------------------------- DATE.. Alterationsand/or recommendations:------------------------------ ---------------- -----------•---------------------------------------------- ----------------..---------------1-..111------- a -•----------------- -------------------------------------------------- -------------------------------------- ----------------------------------------•---•---•--------------------------------------------------------------- .. ----------------------------------------------------------- -••---------------------------1111-- -• ----------------------------1111-------------1111-- .Ti , ----------•--------------------------------1111._ --------------------- -•--•--•-----------------"-------------- --------------------------------------------------------------- --------------------------------------- A, o. -----------------------------------------------'------------ -------------- i fi2_ BY: V_ ; Date_INSPECTION -- ----------- • - ----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT _ 130 Soufh American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lode, California Manteca, California Tracy, California ES---9-2M 10-52 Revised W-2100