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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate) W Date Issued ---- A in is hereby made to the San J?a uin Local Health District for a permit to constru t d ' f 11 the work herein described. gplicafic, L - _j an ins a This application is made in compliance "t County Ordinanc 549 el f-- ' 1/ T4r,7- �� _,� JOB ADDRESS AND�OCATION--- --- - ---- ----- ----- - --------------------------------- Owner's Name------�r� ----- ---- -------------------------------------------------------------------- - -------- Phone- -------------- ---••-------------- Address--------------------1:S700d------- Contractor's Name-----------Vgv� L� ---------------------------------------------------------------------------------------------------- Prone---------------------------------- Installation will serve: Residence Apartment House ❑ Commercial [-] Trail 5r Court F] Motel [] Other E] Number of Jiving units: _/---- Number of bedroomA2.. Number of baths Int size --------US-------- ----------------------------- Wafer Supply. Public system F] Community system F-1 Private 2""Depth to Water Table -------- ft. Character of soil to a depth of 3 feet: Sand 0 Gravel E] Sandy Loam F] Clay Loam 0 Clay E] Adobe g- Hardpan E] Previous Application Made: Yes 0 No F] New Construction: Yes - No [3 FHA/VA: Yes E] No g[ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Distance from nearest well re 1�!.1&4 DistancA from foundation----/ Septic Tank: ---4�0_ Mat i ----- No. of comparfments_.__-12_.- - -----------Size__%wfX.��_f------Liquid depth-------;Tr—,-?-----------Capacity----- Disposal Field: Distance from nearest weII._%ST___ -Distance from foundation ------Pisfance to nearest lot 1 Number of lines__%jr<7 _/------Length of each line of trench =rl-- - -------------------- x I -- -;W --- " _%71----------- Type of filter material____ ____Depth of filter maferia-----z T_ ----------Total length----- t--- -----114 Seepage Pit; Dist,ance to nearest welf '*'#-------Distance from founda'tion--Z�!-"'�-�----.Di��ance to nearest lot Number of pits------_I-------------Lining'- - rnaterial__--Za4_ -------- Size: Diameter-J.47X4--------Depth----/&/-------------------- Cesspool: Distance from nearest well-----------------Distance from foundation--------------------Lining material_____.____________________________ c� ❑ ateria)------------------------------------- 0 Size: Diameter------------------------- ------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well-----------------------------------------------Distance from nearest building------------------------------------------ ❑ Distance to nearest lot lire 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 J'�aquin Local Health District. ----------------------------------------------------------------------------------------------------------------(Title)--------------------------------------------------------------- ------------------------------- -----!------------------------------ (Signed)----i---- ---------�and/or Contractor) By:-/ X (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 BY--------- --------------------- -- -------------- --------r---------------------------------- DATE----------------- -- -- - - ------------------------- REVIEWEDBY---------------------------------------------------- -- ----- ----------------------------- DATE D_ ---------- 4 --------------------------- ------ --- -- ----------- I - BUILDING PERMIT ISSUED---- --- ---- --------- ---------- _------------------------- DATE----------------- ----- ------ ----------- A411"_� ------- ----- Al;fer4af* ns an /or recommendations:---------- ---- -- -- -- -------- ----- �__9(- - ----- ----- ----1-7- -j�;i& ...... I .... �02�T ?�� -------- ------- -------------------I-------------------- ---------------- k- -------/- --- ---- ___1- ----- -------------------------- --------- ---- ----------------------•- - - ----- ---------t---- --4(---M-----a- ----- -------- ------------------------------------------------------------------------- ---------------- -----------------I-------------- ------------ -------- ----------------4------------------______T___._________.----------------- - - -- --------------------------------------------------- FINAL INSPECTION ------ - ---------- Date----�,_- /,_5,--�----(,0 - -- ---------- _----------- -------------------------------- SAN JOAQUIN 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 IrL—?�-,2M Revised 1-57 F.P,CO.