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,✓ ,/ APPLICATION FOR SANITATION PERMIT Permit No. f 57j _ (Complete in Duplicate) Date Issued --- Application _-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 D LOCATION------1t _-_'.yJ.-- l 0 __,3�_�--D-- ' dF ---�' '�.!- '<<<'E'g'"_-_ ---------------------- ; �'_----- ... `+ � --------- Phone - . me Owner s Na a 1- Q t Address--- < a ©X---3 /� � L4!.��_._. ------ ContractorsName---------- --- ----- -------------------------------------------------------------------------- Phon. Installation will serve: Residence I< Apartment House ❑ Commercial ❑ Trailer Court [] Motel ❑ Other ❑ Number of living units: _!_____ Number of bedrooms .Y-- Number of baths I------ Lot size -ld .- ----------------_______________ Water Supply: Public system ❑ Community system ❑ Private Do Depth to Water Table IQ_ ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam )& Clay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No N New Construction: Yes ❑ No FHA/VA: Yes ❑ No (� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well-----------------Distance from foundation-------------------.Material _______________________-_-_.----------------- 5QriSria(5G No. of compartments--------------------------Size_--------------------------- ---Liquid depth--------------------------Capacity----------------------- Disposal Field: Distance from nearest well-------------_---Distance from foundation--------------------Distance to nearest lot line____________--... Vg fCt5•r1tV& Number of lines-----------------------------------Length of each line------------------------------Width of trench--------------------------------.-- Type of filter material-------------------------Depth of filter material-----------------------Total length____________-_-_______________--_________ Seepage Pit: Distance to nearest well---1W_ ______Distance from foundation__' S"'____-.Distance to nearer lot ii ne__�e Number of pits__�YJ.f�____Lining materiai__��OX Size: Diameter__3�_____..___Depth _________________ 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]:--__ -- � -- ��.a- - - -- � �� 77 •- --- --- ., ------------------•---------------•----------------------------------------------•---------------•---------------------------------------•-------------------•-•-----•L----- f ------------------------------------------------------•-------------...---------------------=----'------------------------------------------------•---------- ---------------- --------------------•----------------------------------------- --------------•--------------------------•------------------------ --------------------------------------- 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 regula ons of the/San an Joaquin Lopa`� Health District. '-------- --- - ------------------ (Owner aad r Cont actor) (Signed) �M 8 ..�� .. �-------- --- 144,h/ (Ti+le) r � Y� y.' , d!o (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be place n reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ------------------- DATE-- --------------------- REVIEWEDBY------ ---------------------- DATE 9�--••-- --------------------•------••----•--•-•-- BUILDING PERMIT ISSUED--------------------------------------------------------------•--------------------------------------- DATE---------- -------------------------.... Alterationsand/or recommendations:------------------------------------- -- ----------------------------------------------------•_•------------•------------------•----------------------------- �I------e_.t..----#`----"----------- -- -I-------fn�---------•-- ----- -•-------------�-----`--------------------t--------•--- ----- , "- --" --- --- Iff ------ - - , - --- -------- ----- ----- ` `� ----- ----- --- :-.¢- ---- --------------` .--- ------------------- •------------- -------------- --------------------------------=:= -)'- ------------------------------- ----------------------------------------------------- ---------------------------- ., ----- 30 - 4 FINAL INSPECTION BY:-.---!" ; '''` ------------- Date-----`. .--------- ------�------------------------------•--------------- 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 E5-9-2M , Revises 1-57 F.P-M