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' APPLICATION FOR SANITATION PERMIT Permit No. ........................ (Complete in Duplicate) 3 f— 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 AN OCATION-- ( ......S�`' I .�fi^---------------------------------------------------- ------------------ Owner's Nam -� --------------- Phone------------------------------------ ---------------------- ----------------------------------- Address '+ ----------------- Contractor's Name--------V. ,g� --- --- ----------- ------------------------------------------- Phone----------------------------------- ------------- -- Installation will serve: Residenc Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _---__ Number of bedrooms _11---. Number of baths 4___- Lot size ----------------------------------------------------------- Water Supply: Public system ❑ Community system Private ❑ Depth to Water Table /D ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam 11 Clay� Adobe❑ Hardpan F]Previous Application Made: Yes E] No`� New Construction: Yes No ❑ FHA/VA: Yes ❑ NOA �4 TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or''cesspool permitted if public sewer is available within 200 feet.) Sepf Tank: Distance from nearest welL4.0-4?---Distance from found tion-----ID--------.Material/_ _0 .. '� No. of compartments--_ .______ _______. Size...�_x_ X--,?..Liquid depth---------- /Capacity..._ Dispo al Field: Distance from near st welL__ 00._Distance from foundation.......1-4p.....Distance to nearest lot line__._-_-.... Number of lines______--______r_________ Length of each line)_Z'Z �_ _O_Wiclth of trench_ _.,___4' __' _ _ Type of filter material____-S.__j__ �epth of filter maters"'af_� t lengt Seepage Pit: Distance to nearest well----------------------Distance from foundation__-.•___..--_._._._. stance to nearest lot line_.............. ❑ Number of pits______________________Lining material--------------.--------Size: Diameter-----------------------Depth_---_--_-.------_-__-__--_.----_- (\j� 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---------------------------------------------- r / -----_-,-t-�-----------------------------------------------------`- ------------------------------- ` Remode i ador Q a4 w f ------------ 0 - --------------------------------- ---------------------------- ------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 Joaquin Local Health District. (Signed) �----kMi"'RZ "-------------------------------------------------------------------------------------------------------------(Owner and/or Contractor) By:----------------------------------------------------------------------------------------•-------------------------------------------(Title)--------------------------------------------------------------- (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------------------------------------------------------------------ ------------------- DATE------------------------------------------------------------ REVIEWED BY------------------------------------------------------------ --- --------11 DATE----..�...... � BUILDING PERMIT ISSUED----------------------------------- ¢ DATE .I-------------------- Alterations -Alterations and/or recommendations________________ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--------------------------------------------- --------------------------------------------------------•---------------------------------- ----------------------------------------------------------------------------------------------------•------------------- zedAFINAL INSPECTION BY----------------- - ------------------------------- Date.--------3- 7/� ! 4 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 - Revised 1.57 F.P.CO.