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APPLICATION FOR SANITATION PERMIT Permit No. _IA-A_�), (Complete in Duplicate) / " I . I Date Issued -- --- / 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 9- - - ------------ -- ----- Pva7i ------- / yy / -,; ----- - - --- ! ----------------- Owner's Narne__/"9, v`- ----------------------------------------------------- ------- _ ------------------------------------------- PhoneA ---- Address___.,A1f*`__11. ----- en� --- 133 ----------- 11` Contractor's ------------------------------------------------------------------------------------------------------ - ------- ------------------------------- Phone ------------------------------ Installation will serve. Residence 0 Apartment House El Commercial E] Trailer Court E] Motel E] Of_h_e_r__[]' Number of living units: _/_____ Number of bedrooms ---�__ Number of baths __1 ___ Lot size --- 1L -_ Water Supply: Public system El Community system [] Private [k] Depth to Wafer Table S-q- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel E] Sandy Loam 21 Clay Loam E] Clay ❑ Adobe Hardpan Previous Application Made: Yes [:1 No j?] New Construction.: Yes No ❑ FHA/VA: ❑ 13 No 0El TYPE OF INSTALLATION AND SPECIFICATIONS: 9 El 0 El (No septic tank or' cesspool permitted if public sewer is available within 200 feetJ Sepfic Tank: Distance from nearest well---S-0------Distance fLpb0�0foundafion_JFj -------- Material .... &V711cW4 �p No. of compartments ------ ; ---------- ------- Liquid depth_--- -- ---- Ll ------------ ---------------- ------- A- ------- Capacify-1 --- Disposal Field: Distance from nearest well Aa;_ ------- Distance from foundation --- NO ---------- Distance to nearest lot line-,01 14 Number of lines___-_______ --------------- _ --Length of each'I�ne --------- I-VT ------------- Width of trench._ )4+_ _�, il� -- -------------------- Type of filter material-__ - - -_ A ----Depth of filter material ----- 13Y ___.-Total length ------------------------------- Seepage Pit.- Distance to nearest well ------ --------------- Distance from foundation ------- ------------ Distance to nearest lot line F-1 Number of pits ---------------------- Lining material ----------------------- Size- Diameter_-_-_____-._-_ ------ Depth----------------------- ---- Cesspool: Distance from nearest well _________________Distance Distance from foundation --- -- ------------- Lining material________.____-_______-_____-_____--__. 3 ❑ Size: Diameter-------------------------------------Depth----------------------------- ----------------------Liquid Capacity----------------------- -- -gals. Privy: Distance from nearest well---------------------------------------------- - Distance from nearest building---------------------------------_ -- ❑ Distance to nearest lot Remodeling and/or repairing [describe):_ ----------- - -------------------- -- 4 --- ------------------------- ----------- -------------- __ - ! - 41 --------- ---- ----------------------------------------------------------------------------------------- -------------------- ------ ------------ ----- Cp ------------------------------ --------------------------------------------------------------------------- - --------------- ------------- ----------------- --------- ------------- I ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, Sfrfa laws, and rules and regulations of the San Joaquin Local Health District. ------------------------------------------ V121 (Signed)--- --- ---------------- ---- 01__� a4_L,_� -------- ------- (Owner and/or Contractor) � ----- - ------------------------------------------ --------------- I ------------------------------------------- --------- By: ------------------------•---- * ---- ----------- * ------------------------------------------------------------------------------------------ (Tif le) ---------------------------------------- ------------------------------------------------- (Plot plan, plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------- Ail- :!J�!*`, ---------------------------------------------------------------- DATE-/-q-- -- REVIEWED BY------------------------------------------------------------------------------------------------------------------------------DATE--------------------•- - ---------- ................... BUILDING PERMIT ISSUED-------------------------------------- -------------------------------. DATE---------------------------- - - - Aaerations SSUED--- -------- Aterationsand/or recommendations:_____________________________ I ----------------------------------------------- --------- I ----- --------------------------------- I ---------------------------------- I ------------------------------------- ------------------------- ------------------------------------------------------- I -------------- ------------ ----------- � ------------------- I ---------------------------------------------- I --------------------------------------------------------- ---------------------------------------------- ------------------------------------------ ----------- ---------------------------------------------- -------------------------------------- -------------------------------- --------------------------------------- - ------- ------------------------------------------------------------------------------------------------------------------------------------- FINAL INSPECTION BY_ ---------------------- -------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 614 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES -9-2M. Reviseci 1.57 F,P,CO.