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n" APPLICATION FOR SANITATION PERMIT Permit No. ._ __.... (Complete in Duplicate) 11) _ Date Issued ___.._ Application is hereby made to the San'-Joaquin Local Health District for permit to construct and install the work herein described. This application is made in "compliance with County Ordinance No. 549. JOB ADDRESS AND LQCATION___-_--'____"" Owner's Name---------------- C7- ---------IV"F'41 -•--------- -.... Phone --------------- Address-------------- �. ..__!. Contractor's Name------ ---- -------- ----•-------- Plione �_?r'f✓�,�� - �.�• .. ' Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ OtherE) Number of living units: _1-._ Number of bedrooms e'_' __-Number of baths __.r/_ Loisize 4 __"_/n�_Q-__ Water Supply: Public system N. Community system [IPrivafe'❑ Depth to Wafer Tablevo- ft. ' Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ -Clay ❑ Adobe,& Hardpan ❑ Previous Application Made: Yes ❑ NoR New Construction: Yes ❑ NoX FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) Se k: Distance from nearest well---------------- froml'foundation___________________Material""----___._.------------------------------------ N6. _._______- ""-"-:""" "_--"""_"-_„ ' No. of compartments--------------------------Size-------------------- --------- Liquid depth------------------- - - ' Capacity---•-=----------------- s ` Disposal Field: Distance from nearest well___14. .. Distance from foundation". c��4!---------Distance to nearest lot [ine_1 Number.of lines----=._/-----------------------Length of each line--------c;;2 `/ -----.Width of trench_. "�/-___" ............... Type of„filter material------�L ----Depth of filter material------ length-------�_:S_--f ------------------------- Seepage Pit: Distance to nearest Well--- ell-- M1.i✓F__-_Distance from foundationl__•____".Distance to nearest lot Number"of pits_____ _____Linin material____-,�a .Size: Diameter__...___ 9 ,. Depth--- �_,$"----------- Cesspool: Distance from nearest well-----------------Distance from foundation________________Lining material----------- _-_------------------------ Size: ❑ Diameter-------------------- -------------Depth---------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest we]--"" _ I ' _________________._.---------Distance from nearest❑ building-- Distance to nearest lot line._:__'_:__...__ "'"�^ -- .. Remodeling and/or repairin� (desc.i e):_---__ - --•-•---------------------------•- - - - 7 -------------------------------------------------------------------------------------- - -- --- --- -- --------- - - ---- ---•-- •----- - --- ----- 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, rules and regula� of the San Joaquin Local Health District. F i (Signed) -------------- -----�-- - ----- owner and/or Contractor) By:----------- - =-----------{----------------------- /1'� (Title)--•--L - - ---------- ---- ---- - - - - -- --------------- Plot plan, showing size of lof, location of sys em in relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY } APPLICATION ACCEPTED BY------ ""--- - ---- -----"-"-- DATE-----"""/.-- BUILDING -_;._,L) ------------------------------------------------------ BY ------------------------ --- ----- --- - -------- -- ----------- DATE------- __`. -- --------------------------- REVIEWED ----PERMIT ISSUED-------------I_.i- - r ' 4 •----------------------------------=---------------------- DATE , Alterations and/or.recommendations:.-__ ---- -•--- FINAL INSPECTION BY:_. _> . ':.- �" Date--- 7 € -- �--------------------------------- SAN JO QUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California ' Lodi, California Manteca, California Tracy, California E5-9-•-2M , Revised 1.57 F_P.CO.