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T Permit No. APPLICATION FOR SANITATION PERMI -_T.J ---•- f 1� (Complete in Duplicate) Date Issued � it T•-- "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... /G IT%/Y -------------------------------- Owner's ---------------! r- ------------------•-------------------------------- Owner's Name-----------•-------------------------- 0y---- 1JI'i� &Y---------------------- - ---- -------- Phone_ Address------------------------------------------ F------ ----------------------------------------- ------------.--- r --------------- Phone- Contractor's Name-------------------------------- ��'��_�- ----------- --------------- Installation will serve: Residence Tg Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ A��` �p- ----- - Number of living units: _�-- Number of bedrooms _�-_ Number of baths ._�____ Lot size __b..� -- Water Supply: Public system Community system Private ❑ Depth to Water Table If ft.--0- Character t.-#Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ AdobeA Hardpan ❑ Previous Application Made: Yes ❑ No W New Construction: Yes ❑ No ❑gtLr j ce- ....,. TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) S tib k. Distance from nearest well-----------------Distance from foundation--------------------Material_____-______._-------__________._-..._...__-_ No. of compartments--------------------------Size-----••-------------------------Liquid depth--------------------------Capacity--------- ------------- DJ o a d Distance from nearest well-----------------Distance from foundation--------------------Distance to nearest lot line--------------- - Number of lines------------------------- --------Length of each line----------------------------..Width of french----------------------------------- Type ---------------------------------Type of filter material-------------------------Depth of filter material-----------------------Total length------------------------------------------� See a e Pit: Distance to nearest well-1111140.KC----___-Distance from foundation___- Distance to nearest lot line___.. --~' Number of pits.---4----------------Lining material U4.- ------.Size: Diameter-- - -�•-------Depth_-- --a-_-�--------------- Cesspool: Distance from nearest well______________ __Distance from foundation-----.------.-------Lining material--------_____._____----______.__.__ ❑ Size: Diameter----------------'---------- Depth--------- - ---------_-Liquid Capacity------�--•-- ----------gals. Privy: Distance from nearest well_____________________________________________--Distance from nearest building-----------.---___________-__._._._-- ❑ Distance to nearest lot line - --------------------------- ---------------------- ------------------------------------------------------------------ Remodeling and/or repairing (describe):------------ ---------------------------------------------------------------------------------- --------------•---------------------------------------- w -------------------------- -------------•-•-------------------------------------------------------------------•-- ------------------------------------------------------------------------- I hereby certify +h I ave prep red this pplication and that the work will be done in accordance with San Joaquin County ordinances, State laws, n rules and egula io s of the San Joaquin Local Health District. Contractor (Signed)------------------- ---- -- - - - - --- ---------- ----------------- ------------------------ ----------------- - ---- �� ) -------{Title) � h'114-70— .._-- ----------------- (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-- ------------------------------------------------s----------------------------- ------ DAT ---------------------------------------------------- REVIEWEDBY-------------------------------- - ` DATE. ------------------------------------------------- BUILDING PERMIT ISSUED------ - DATE - -Lp --------------------- ------------------- Alterationsand/or recommendations:---------------------------------------------- ---------------------------------------------------- ------------------------------------ --------------------- ---------- ----------------------------------------------------- ------------------------------------ -------------------------------------------------------------- -------------------- --------------- FINAL INSPECTION BY:---- ;----------------------------------- Date--- ---- `a' .------- -------- 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 ES-9--2M 10-52 Revised W-2100