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APPLICATION FOR SANITATION PERMIT Permit No. __4� (Complete in Duplicate) litDate Issued -------------------- Application _-----y7--SApplication is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This applicatiori.is.made_in_compliance-with-County.-Ordinance No.-549..--- - �f -------------=---------------- JOB ADDRESS AND LOCATION._____�7' - - -- - J 'S' ``kms �7jt t<_ «t -------------------- Phone.------------------ a Owner s Name --IA ---- - - -=--- - . ` " f--------- - Address---------- - .O-�----- - -t-=R1 _ -�i� ------------------------------------------------------ -- ---;-;-- - ------•- Contractor's Name--7- ._�_ _� , u_M8 _ht�j -------------- Phone ._ _ Installation will serve: Residence [Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ S©0 I t Number of living units: __1__ - Number of bedrooms _;�__ Number of baths ________ Lot size _____J -------------------- Water Supply:- Public system Community system ❑ Private 0 -,Depth to Water Table __k ft. Character of soil to a depth of 3 feet: Sand ❑-Gravel'❑ Sandy loam [_1Clay Loam ❑ Clay Ll Ado Hardpan ❑ Previous Application Made: Yes ❑ No � New Construction: Yes ❑ No Z FHA/VA: Yes E] No I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public strwer is available within 204 feet.) I n Septic Tank: Distance from nearest well___ Distance from #ouncr fl n---- -----------Material_____ �_l�__ _ - s - Septic No. of compartments---------- --------Size � k. Liquid d epth Capacity Dis o I Field: Distance from nearest ell- _ ___._____ "Distance'from -----------Distance to nearest lot line__�.----- p foundation__.1'. Number of line Type Length of each line-----------44 Width of trench---- ---`�--------------------- { t� - Type of filter material_.__.__ s+�Depth of filter material______ _ ___________Total length, 9 Seep a e Pit: Distance to nearest:well_____________________D-istance�from foundation------------.-------Distance to nearest lot line----------------- ❑ Number of pits------------------..__Lining material!'---------------------Size: Diameter_-----------------__- -Dept h------ -------------------------- Cesspool: Distance from nearest weld-----------------Distance from foundation---------------._-- Lining material.___.._____---___._________________. q ❑ Size: Diameter----------------------------- --------Depth------------------------------ ----------------------Liquid Capacity-- -------------------------gals. _ Privy: Distance from nearest well----------------- ----------------------------Distance from nearest building--_---------- ---------------------------- ) Distanceto nearest lot 1ine-------------------------------------------------------------------------- ---------- -------------------------------------------- Remodeling and/or repairing (describe):--------------------- ----- -----------------------•------------------------------------------------------- --•----- ---------------------------------------------------------- - y ------------------------ ------------------------------- 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 regulation of the San Joaquin Local Health District, e --- - arl 1 (Signed)----?-- ontract - ------ �or ----------------- -------------------- -------------------- By-------•-• -- ---, ------------(Title)-------------------------------------------- (Plot plan, showing size of lot, location-of-system' in relafion to we'fls,lbdil S. etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY------------------------- ----- -- ---------- DATE---------- -i .. ._ --1 REVIEWEDBY------------- -------------------------------------- ---- - rr DATE---- --- ---. ----------------------------------. --. BUILDING PERMIT ISSUED-------• •------------------- ------- DATE------ -- -- -- ------------------------------------ ---- Alterationsand/or recommendations:------------------ ------------------- ----------------------------------------------------------------------------.-.--------------------------------------- ------------------------------------------------•------------------------------------- --------- ------ -{-/-�{ G- -- -------- ------------ ---------------------------- ------ -- ------- --------- '------------------------------ - ------------------ice ------------ -------- - / - ------------- _7------------ ✓.-_----- --- ---- Date---------- ------ -- ---------------------------•---- SAN JOAQUIN LOCAL,HEALTH�DISTRICT 4 130 South American Streaf 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.