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1 APPLICATION FOR SANITATION PERMIT Permit No: in Duplicate) 7/ c (Complete P � Date Issued .----_f__�' _-�--• G Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. /'phis application is made in compliance with County Ordinance No. 549. L C ------ _uj %` 'fi: �----- - JOB ADDRESS AND LOCATION----------------------------------- J Owner s Name w"'✓----- -al--t-- Phone __.A- -- --�"'---�-� -- r _ Address + "" ```' --t--- �------------•---------------- --------- ------- ------------------------ S --- Contractors Name__.1__J_ _.+1}. .- --�-_-- . - ------------------------------------------------------------------------------------ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ,13s ther u f Number of living units: _-�.____ mber of bedrooms __ " Number of baths __i____ Lot size �' ----- - ---------------- ----- ------ Water Supply: Public system Community system ❑ Private ❑ Depth to Water Tabler'--- ft. Character of soil to a depth of 3 feet: Sand Gravel L]" Sandy Loam , Clay Loam E] Clay E] Adobe Hardpan E]Previous Application Made: Yes F1No New Construction: Yes No ❑ FHA/VA: Yes ❑ No 0 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Ta -----------------Distance t wellSance from foundation--------------------Material----------------------------_----------------- m1Z _ -----------------Liquid depth--------------------------Capacity-•---------------------B ' E A Disposal Fief Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line___.______--_.._. Number of lines-----------------------------------Length of each line--______- ----------------Width of trench---------------------------------- Type of filter material------------------------Depth of filter material-------------_---------Total length___te _.__ ________-_---.--_- I �.-.-`t �_.___Distance from foundation___.' �ar Te to ne lot line- _ ___ P Number of pits_____ ----------------Lining material_ .1___-----Size: Diamet r" "____ `�__ pe - --{___ ___._:�__See .a Pit: Distance to nearest well__:____Cesspool: D•stance from nearest well_______________:Distance from foundation_-._'__-- _____-- i Ing ma eria--_ - - � 1 ❑ Size: Diameter------------------ --'--------------.Depth----------------------------------------------------Liquid Capau- -------__ _ _ gals. T r _____Distance from nearest building r:vy: Distance from nearest well-------------------------- 9 ❑ _ ---"----- Distance to nearest lot line----------------------------------------------- --------------------------•- ------------------------- ---- --------------------- ______________________1____._ __ _�_________U s.____- " Remodeling and/or repairing (descri6e�:___-_:_._ ---------------- ------•-- �-- `�IA�� AI ----------------_------------------------------------------.-------------------------------------.----------------------------------------------------------_------------------------------------------------------------------ yT\S^\yf' --'------------------------------------------------------- --------------------------------------•-------------.-----_----------------------------------------------•------_--•_____--•------------------------------- ...... Y 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 and/or Contractor) (Signed}--- -- --------- -------------`-°i-� - ------ ----------- t� � L -4 Title ' --------------------- gyc `= -- ----- --. --------- - ------------------------ - --- c?�i ( 1 - ,0- (Pla# plan, showing size of ot, location of system in relation to wells, buildings, etc., can be placed on reverse side). P. FOR DEPARTMENT USE ONLY y ! APPLICATION ACCEPTED BY------ ----- ------------------------------------------------------------ DATE-- -�------------------------------------------------ } REVIEWEDBY-------------------------------- -------------------- ------------------------------------------------------------ DATE_ " � � ------------------------------------------ BUILDING PERMIT ISSUED------------- ------ ---N DATE----------- -� - �. Alterations and/or recommendations:------ --- --------------- ----------- -------- ------------------------- -----•-•------------•---- --------- F - ----------------- -----------------•---- --------------•----------- - ---------------------------------------------------- - - --------------------------------------I-------------------------------- --------------- FINAL-,INSPECTION BY:-- ------------------------- ---------- Date--- ---- y r -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street $14 North "C" Street Stockton, California 14.. Lodi, California Manteca, California Tracy, California ES-9-2M Revisers 1-57 F.P.,CD.