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1 APPLICATION FOR SANITATION PERMIT Permit No. ! (Complete in 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. This application is made in compliance with County Ordin No. 549. JOB ADDRESS AND L CATION---.,___l ©------- ------ I__-! / --------------•----------------------------------- Owner's Name -------- ----`-- ---------- ----------------------------------------- Phone--- Q Address---------------c;2914Q Contractor's Name._____-----/---"5------- - -------- ? -- ---------- ------------- Phone---------------------------/------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ OtherT4�.e 11P Number of living units: -------- Number of bedrooms -------- Number of baths -------- Lot size________________________ Water Supply: Public system a Community system ❑ Private ❑ Depth to Water Table . .- _ ft. Character of soil to a depth of 3 feet: Sand 0 Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe& Hardpan ❑ Previous Application Made: Yes ❑ No K New Construction: Yes Od No ❑ FHA/VA: Yes ❑ No TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet) ` /A ®�C, i Se t' Tank: Distance from nearest well--t40.___Dista e from fo dation___________________Mat Vial____ ________________ , __ ------- No. -__ No. of compar#ments_____�______-.-_-fSize _` ---. .'�"..:---Liquid depth------------------------Capacity---4J- " OAJ a Disp I Field: Distance from nearest well_- ..x,_____ Distance from foundation.____-____Distance to nearest lot}ine_ ___._._____ Number of lines-------- ' ri__- . -- _Length of each line___ ,,F--.Width of trench___e --7 -------------- ______ Type of filter material _ s -eepth of filter material r Total length. ---------- Seep ge Pit: Distance to nearest well__/"-_______Distance r u dation-----/Q----___ i qp to nearest totyiine�_______ Number of pits---- Lining materia-�'�_ ' ize: Diameter..________Depth__�45�---------------____ Q Cesspool: Distance from nearest well-----------------Distance from foundation---.--------------..Lining material-------------------------------------- ❑ y. Sith-------------- -------------------------------------Liquid Capacity- --------------------------gals. i' ze: Diameter--------------------------------------Dep Priv Distance from nearestfwell F1 Distance to nearest lot' ll _ _ __ _______-_____:____:._Distance from nearest building ----------------------------------------- Remodeling and/or repairing (describe)------------------------------------------------------------------------------------------------- --------------------------------------- ---------------- ---------------------------I------ -----------------•----------------------------;---------------------------•-------- -------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------------------------------------------•-------------- ----------------•----------------------------------- - I h------------------•----- ----------------------------------------•-----------------------------..--•------------------------------------------------------------------------------------------------------------ ereby 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 regul tions o the San Joaquin La Health District. (Signed)_.`__..64- ____ _ _____________{__.,_ xA0___-Jwrier and/or Contractor) -4- ----------------------------------------------------------------------------------------------------- --------(Title)-------------------- --------------------- ------------------------------------------- (Plot plan, showing size of lot, location of system in relation to wells, buildings,,etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY------------------------- ---- ---------- --- - ---------------------------------- DATE----- -- - - ------------ REVIEWEDBY--------------------------------------------------- - - - -------------------------------------------------- DATE----- ---/----------- ------------------------------ BUILDING PERMIT ISSUED----------------------------- ------ ----------------------------------------------- DATE Alterations and/or recommendations:__,$_---1.- .-_----4z_I______..._r ,r ,c( -----_- -,---_- ,�- _„--------- 5 ------•--- ------:)n�a - , e� K t>�s Q, � :w_�6�s t"� -fix'� -------f' - 1nl.�S - .- ------- ------ .--------e..... ---------------------------------------------------- - --- -------------- �ViA,- � �s ----.-tai- • '�• 1. -fil. ------- -h,�A�"-----�..Q.el�s-�-��------��-- 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 ES-9-2M . Revises 1-57 F.P.CO.