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APPLICATIONFOR SANITATION PERMIT Permit No. ------ A-1— i , (Complete n Duplicate) Date Issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. i This application.is+made in compliance with County Ordinanc No. 549. ' I f ---------------------------------- JOB ADDRESS N LOCATION-- -- -�-�--�- ----- -"�- ---- - - --_---------------------------•----------- Name------ r "--------"--- ------------------- -------- Owner'sPhone ---------------•--- -------------- Address ._ _ - ---------- i = 7 4. --.--- - Contractor's Name_______________ _ "-_-. . Phon __ _. Installation will serve: Residence;[Apartment House El Commercial ❑ Trailer Court ❑ Motel ❑ Other E] ___ Number of baths ___ _ Lot size _"_ - Number of living units:�-��__ Number of bedrooms � - - ----""-"-"- �-� ��- �-------------- 'TSS ++ obDe th to Water Table 3_�_ ft. �-- Water Supply: Public system [ Commun'ity system'❑� Private ❑ - P-_Y. ,�. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe SQ. Hardpan ❑ Previous Application Made: Yes r❑y No New Construction: Yes �No ElFHA/VA: Yes ❑ No E] 1 TYPE OF INSTALLATION AND ;SPECIFIIONS: 5e tic T Distance from e},�� ( p l ermitted within r nnearesi-welf public Distanceafromefounda?oa__, ________.Mater�l_ No septic tank or cess oa p _Ca acitQ ------- I'--- No.of compartments____ _ _ _ Size_____ _. - _3A6----Liquid depth_--____ p y- - -- Disposal Field: Distance from nearest wel�Ey.,--_____.Distance from foundation? --------Distance to nearest lot line______ _______ ' Length of each line_________," i_ Width of trench___- __" - -------- -- �/ Number of lines-- 9 Type of filter materi -- - - �- Depth of filter mafferial_-g-- ------;Total length-----/V?_0----------------•----.-- Seepage Pit: Distance to nearest well_____________ Distance from foundation----._______--------Distance to nearest lot line-----.________._ ❑ Number of pits-----------------------Lining material------------"- ------.Size: Diameter Depth Cesspool: Distance from nearest well______-:______-_Distance from foundafion_,_.------I---------Lining material------ ---------------------------- . .- ,• Size: Diameter- -------------Dep#h----------------------------- ------------I------- Liquid Capacity gals. X11 Priv -=------------ ------Distance from nearest'well___________________--------------------------Distance from nearest building_____-.._______________ ❑ Distance to nearest lot line---- ---- ------------------------------ E Remodeling and/or repairing (desci ibe)---------------"--------------------"---------- -------------------•--------- ------------------------------------------------------------------------ ` 1 L •----------------------••-•-------------I------------------------ ------------- ".t -----------------------------------------------"------h---------------------"-----------------------------------"------------`-"- - --------•----------------"--------•-`------ ! hereby certify that I have prepared this apislication 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. - ---------------------- " _________(Owner and/or Contractor) (Signed � " ------------------- '.F={Tit By------------------•------------------------- ---- le) (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., cn� be placed on reverse side). FOR DEPARTMENT USE ONLY ,, 4 - ----• ---k"NJ' DATE •� APPLICATION ACCEPTED BY----------------------------�- ---�-:--"---------- -----" - -- ----"----- REVIEWED BY f DATE -~' ---------"------. BUILDING PERMIT ISSUED--------- = _ DATE - --------- ------- -- Alterations a, or recomme�t at ons:_^- -_.- ----- ---- �1 -------------------------- --- -"---_- 3 ---------------------------------••------•------------- ---------------•--------"---------------------------------------------------------- ------ �/ ---------------- - ---- ----- ---- - -----------------------------------------------------" ------- --------- 8 S FINAL INSPECTION BY:= � tLQUIN ------ " SAN LOCAL'HEALTH DISTRICT S 1 130 South American Street 1 Soo 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'