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1, APPLICATION FOR SANITATION PERMIT Permit No. ...... (Complete in Duplicate} I. w - • Date Issued ! x .s� Applicafion 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 JOB ADDRESS AND L ATION------ ----- -- `�f/ , Owner's Name ------------- - ------ Phone_ - - d �. - T 313 Address---------------------- - � - /�j Contractor's Name---- ----- -C-/.__-- . .. -------------------------------------------- o rr'D Installation will serve: Residence Apart ent House ❑ Commercial [-ItrailerCourt ❑ Motel ❑ Other E] Number of living units: __/_ Nu`mber-of' bedrooms __ _ Number of baths __/__ Lot size �------------------------------------- Water --------------------------Water Supply:: Public system 'Commun'ity system ❑ Private❑"Depth to Water Table _Zl ft. E Character of soil to'a depth of 3 feet: Sand E] Gravel ❑ I Sandy Loam ❑ Clay Loam ❑ Clay ❑ Ado Hardpan ❑ Previous Application Made: Yes ❑ Noxi New Construction: Yes ❑ No FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND'SPECIFIICATSONS: (No septic tank or`cesspool permiffed if public sewer is available within 200 feet.) . �gl Distance from nearest well_________________Distance from foundatio - Matariai-_-_--_____________-_________--___:_____________. No. of compartments _______ p Size - Liquid de pjh Capacity----------------------= ispos Field•. Distance from"nearest weal`_____-.____:_=.Distance from foundation ________________.Distance to nearest lot line_ ___ Number of lines----------------- ----------------Length of each line------------------------:- _-Width of trench__________•.---------------------- Type of filter material______-t- ----- .__ ' p -- De th�.of,filter-material-------------=---=-�-.Total length------------------------------------------ [l -� Number of its__ ___ ______��_____Linin material--'- ___[IUlSize:rDQ "Distance to nearest lot Seepage Pit: Distance to nearest well_1�4 ,Distance r fo dation,-- ,meter___�+t ��.L p g is - --------.Depth---� -- ----------- Cesspool: Distance,,,from,nearest„well -------------:_Distance from €oundation ___-------r`-.Lining material_-__'_________________________________ `1] Size: Diameter ( Depth = =� Liquid Capacity----------------------------gals. �. Privy: Distance from nearest well_____6________________,----_____.__._______._____Distan e from nearest building_________._-----_________-__._______----. ❑ ,.= Distance to nearest lot-line----r---- "= = - - Remodeling and/or repairir g (describe]:__.-_-__ --_ ` ------------------------"----- -----•--------------------------- -------------------•----•---------------------- -:----=--------- ------------------------ ------------------••------------------------- s • a I hereby cerfif that I ;have repared this applicafion and lthat.the work will be done in accordance with San Joaquin County ordinances, Sfa ! s a rule' an !regulations of he San Joaquin,Loca{ Health District. t (Signed) •--------- t--- ------- - - (Owner and/or Contractor) -------------------- - - -------------------------------- BY= -------- ---------- - - -------------------(Tifle)------------ --- ------------------------- (Plot plan, showing size of lot, location of system in.relation�to well buildings, efc., can be placed on reverse side). FOR DEPARTM T USE ONLY APPLICATION.ACCEPTED BY-------------'------------- --- ------- t'= sir.. K, : DATE REVIEWEDBY---------------------------------------- --------- -------- -- ---- ------------------------------------------------ DATE- ------------------------------------ BUILDING ------------- ------ -- - -- ------------- BUILDING PERMIT ISSUED-------------------------------- --- - - ---------------------------------------------------- . DATE-, - ----- Alterations and/or.,recommendations------------------ - ------ -------- ------ •------------------•----------------••----•------•----- /_.,3 tT ��. - � -- --.-_-_-___�-_ -------7 � = ------- ---------------------------------_------_------ _1A- -------/ti0___---__..�- q -------- ______ ----------------------------------------------- ---------- FINAL- INSPECTION'-$Y:= ---- --------------------- 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 M6nteca, California Tracy, California _ ES-9-2M ReviseG 1.57 F.P.CO. d