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{ APPLICATION FOR SANITATION PERMIT Permit No.:....1___!___7_/ v a {Complete, in Duplicate} w F Date Issued ____��5��-- a 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. F 6 "' do 70, 04 _ ' = JOB ADDRESS AND CATION___-__--__ Owner's Name--------/-- - ---- ---- Phone. -------- Address ----- ------------------- ---- -------- Address-------- - Contractor's Name----�' ----••-•---------------------------------------------------------•--------------------•-•-------•--- Phone----------------------------------- : � I Installation will serve: Residence r Apartment House ❑ Commercial ❑ Trailer Court E] Motel ❑ Other El ` Number of living units: _ ..___ Number of bedrooms�� Number of hs .L.___. Lot size ----------------------------- i Water Supply: Publicsystem ❑ .Community system ❑ Private Depth to Water Table -------- ft. , Character of soil to a depth'of 3-feet: Sand ❑ Gravel ❑ Sandy LoClay Loam E] Clay ❑ Adobe'�rdpan F]Previous Application Made: Yes ❑ No New Construction: Yes ;'.-No ❑ FHA/VA: Yes ❑ No LJ� TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool.permitted if public sewer is available within 200 feet.) Septic T k: istance from-nearest well---------------_Distance from foundation_-_- _.__--------.Material------_-_____-__----.-.----_-_--------.-___-.--. o. of compartments------:----------------- Size--------------------------------Liquid depfi -------------------------Capacity---------- -._ Dispos I Fie istance from m nearest well.,5.0----__Distance from founda ' n__. ---------Distance to nearest lot lir��e---.1„?__-_-- Number of lines_~__.__ nth of each line___. _ ___ ___ _ :_.Width of trench_ _ - g r yti Type of filter material] ___Depth of filter material_______ _ ____Total length_____l _d._-.__--_______._____._ Seep ge,Pit_ Distance to nearest well:----- �_--- ----_---Distance from foundation-----------ri___:::Distance to nearest lot line_______.__._____ .. Number of its.--- ----------------Lining material--------- Site: Diameter`------------- --------.Depth----------------------------=--- J Cess ool: Distance from nearest well______________---Distance from foundation_-__.- --_-._.___,_Lining material_____ -__---_.---._-_----_______-- Q i P T p 1 r ❑ Siie: Diameter------------------ ------------------ Depth-----------------=--=--_; =--------=;�- Liquid Capacity gals- - Privy: _ Distance from nearest well-------------__'____.__________.----.---------¢Distance from nearest building------ A l El - Distance to nearest lot line- - ----_ - 'r --------- ir t yg / p------g (des b6- :------•-•-•---'---= --- -------- f-_ _ - -= Remodelin and/or re amn describe _ t . I _. --------=----------------------------•------------------------ Y -------------- i --------------------- _ I hereby certify that I have prepared this application and'that the work will be done in accordance with San Joa uin County q ordinances. State laws, and Arles and regulation of the San Joaquin Local Health District.; Signed)_ �1 _ '-�. --------� --- ----- ---- ------- --- 1 i'..- `{Owner and/or Contractor} ---- ------ --- , Plot Ian, showing of lot, location of system in r ---- - - ------^-'--------A ;-----------•----{T't e}---------------------------------------------------------------- (Plot -------------------- ( p g y elation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY 1 APPLICATION ACCEPTED BY------------ --W ---- -- ---------------------------------------- DATE------- --- X -------------- -_-:-Y-------------------------------- REVIEWED BY---------------- --- -.- ----- ------- - ------- ------------------------- DATE �� BUILDING PERMIT ISSUED------------- ... -------------------------------- DATE Alterations and/or recommendations:- ------------------------------- -----------------------------------•------••---------------•------------- ---------- a -------------------------- -------------------------------------- -----•-•---------.----•-----•--•- -------•---- --------------------------------- ------------------------------------------------------------------------------------------------- ---------; ----------- -----_- FINAL INSPECTION BY:.. Date. I--- - --------- ---- P� ------ -SAN JOAQUIN LOCAL ALTH DISTRICT Sycamore Street 814 North "C" Street 130 South American Street � 300 West Oak Street 132 5 Y t Stockton, California Lodi, California Manteca, California Tracy, California i eS-9-2M Revisoci 1.57 F.P.CD.