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APPLICATION FOR SANITATION PERMIT Permit No. (Complete in Duplicate)- Date Issued Q 17" lzl f 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. �r z 170--LtZ JIle OB ADDRESS AND LOC TION- 1� ------. --------------------- -•----------------------------_ F Owner's Name------- �----------------------- --------- Phone/-5-,5 - Adress -- - ---------- -- ---------------------------------- ` z, .� s Contractor's Name-------------1 -•er P -------•- ---------------- --------------- ---------------•------------------------------------------ Phone----------------------------------- Installation will serve: Residence's Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ " Number of living units: __ -- Number of bedrooms __Number of baths _ ____ Lot size _____ _//^' �_ _ kr - d_ ---- ----- --- Water Supply: Public system ❑ Community system ❑ Private [ Depth to Water Table ________ ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe)X Hardpan [j Previous Application Made: Yes ❑ No A New Construction: Yes E] No I TYPE-OF INSTALLATION AND SPECIFICATIONS: �� t I (No septic tank or cesspool permitted if public sewer is available within 200 feet.) 4 Septic Tan)C: isfance'from nearest well-----------------Distance from foundation--------------------Material..--------------------------__._______________.,„ ❑ 'of compartments------------------------It-Size--------------------------------Liquid oSdepth-------------------------Capacity------------------ / I Dis c field: istance:from nearest well__/. k____.Distance from foundation I___Distance to nearest lot line_-______- Number of lines____________ --------------------Length of each line________&_-__---�f__-Width of french----------3C7_____________t_ Ty of filter material___,5__T_�Depth of filter material--__---__/Sj___-___Total length-vb Seepa it is nce to nearest ell_____ _ �_____-Distan10 found ron_ .1 I�-- -__-.Di an6 o n rest lotine_________________ umber of its______ Lining al Size: Di ter___ _ Dept '__________________________ Pi -------- Cesspool. Distance from nearest well-----------------Distance from foundation--------------------Lining material________--._________-______•---_____. .k ❑ Size: Diameter--------------------------------------Depth---------------------------------------------------_Liquid. Capacity----------------------------gals. I _ Privy: ..,. .r ��Distance�fromYnearest-well== ___ =" _=(}istance_from�n�arest buildin ❑ Disfance.to nearest lot line------------------------------- - _----------.-----------------------�---^--------------------------------------------fJ----------------- Remode ng end/or pairi ng describe): r- ` _ ._/! ILG-r- ----------• r --------- � _.._. . ----- ! '4 --------- --------------------------- her�r+�a I have preps d this application and that the work Ill be done in a rdance with San Joa ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. li (Signed)______ - __ ____-- _ [Owner and/or Contrac+orJ ---- ------- --- By'-----------------------------------------I-- -----------------------------------------------------------------------------------Title)------------------ -------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). OR DEPARTMENT USE ONLY APPLICATION ACCEPTEl7 "l3Y- ` DATE---(�� ---------------------------------------- REVIEWEDBY - v ----------------------------------------------- DATE----4 - --------.__.---------------------------- BlJfLbING�#'ERM41 1551 °EDS ------ ------ -------------------- --- -----------=---- ----DATE _ ----------- -------------------------- Alterations -------- ------Alt rations and/or recommendatio s: -------------- ------- ---------- --------- " - ----- - -. - ------ ---- --- - 9 tT ------ - -- --------'""r---rQ- --- ------------------- - ----- > ` FINAL INSPECTIO BY: - - Date--------------------/Q- _Z_/__-_, � SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street.: 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California I Lodi, California Manteca, California Tracy, California ES—'9-2M 8-51 Revised W-2100