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APPLICATION FOR SANITATION PERMIT Permit No. _��~ _9 S� (Complete in Duplicate) _7/ Date Issued 171-��- r h. t Applica+ion is hereby made to the San Joaquin Local Health District for a permit to construe and install the work her m described. This application is made in compliance with 'ountj- Ordinance No. 549. ��' JOB ADDRESS AND LOCATI9 - _ -- ._- - -- ------ ----------- - 11� Owner's Name +/� --- ---- ---------------- ------- Ph0ne_ `_�?_ f4r_{1 Address------•---r�---r--- - - - :......T, V -------------------------------------------------------------- Contractor's Name____ ' -------- ----------------------------------------------------------------------- --- ------------•----------- - Phone--__----------- Installation will serve: Residence ®Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Ofher ❑ ` r ' Number of living __ _,� units- _ _ Number of bedrooms _ Number baths __ Lot size -- 7CS.-JV_Z. _9P_ r ► Water• Supply: Public system ] Community system ❑ Private Depth foTter Table -------- ft." ' Character of soil to a depth of 3 feet: :Sand ❑ Gravel ❑ Sand ''Loam ©f Clay Loam ❑ Clay ❑ '"Adobe Hardpan E] Previous Application Made: Yes ❑ No W New Construction: Yes N/'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: r [No septic tank or cesspool permitted if publi sewer is available within 200 feet.] / 4�': r FSepk: Distance from nearest well7---� Distance 4om ' and -i�n_�_a________- Mater•aI -No, of com artments_..__---- ------- ------------- p + 5ize :oa- squid dept---:° Capacity Dispo 9� Y "t j---- Field: Distance from nearest wel V--_---Distance from foundation_-_ _ - , ____.Distance to nearest lot line:_f7 -___ N Numl7er of lines________ -__ Length of each line-------------- Width of trench_----------- Type �} K Type of filter materi ___.__f Depth of filter material---_._ � +----- ------------_---- Seepage •• - Seepage 'Pit: Distance to nearest well___-------------------Distance from foundation---------------------Distance to nearest lot line_________________ i. ,:. � _ � ❑ I�umher of pits.-=---- _= mining material-----------------------Size: Diameter---=--- ----------=.Depfh------------------------ -- Cesspool- Distance from nearest well ____ ____.__Dk from f7un at�ioli _--T-Lining malarial__ T - ------- "----- ----------' , ❑T Size: Diameter--- ----------------------------- Depth-------------- --------------- ------- f' ------Liquid Capacity-. �"ga4s- Privy: i Distance from nearest well_______________ 1.44-------------------Distance from nearest building---,-------------------------------------. A ❑ r Distance to nearest lot line------------------------- ------------------------------------------------------------------- Remodeling and/or repairing (describe):------------------ = 4 ------------------------• --------------- ------------•-----=------------------------------------------------------------------------•----------�----------•------------•---------•-----= =�` -- *. ---------------------------------------------------A----- --------------------- ---•------------ -------------------------------------------------------------------------------------------------- ----------------- 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 regulations of the San Joaquin Local Health District. q ------------ -- -- -----------------------------------------------------------------------(Owner and/or Contractor) sY? 1: ----------------------------------]Title)------- --------------------------------------------------------- (Plot plan,,showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 1 _ FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED SY ___ ? DATE�-•-_r"` ------ ` -- ------------- REVIEWED BY--------------- --- -- DATE-_- - t BUILDING PERMIT ISSUED---------- - ---------------------------------- :.—DATE _ Alterations and/or reGommendatio`rj}s:� Y •-----------•-------- -------- -- ------------- ----------- --•- •--------------' A -- -` --------- -- .. ---------------------------- _.. ------- ----------- ----------------------------------------------------------- -----•--•-------------------------------------•--------•------- ' f "- -'- ---------------------------------------- } FINAL INSPECTION BY:. -----•---- --=�------------ ----•---- .. Date V , s ------------------------- SAN JOAQUIN L"OCAL HEALTH DISTRICT 130 South American Street 30D Wes+ Oak Street '}, 132 Sycamore Street 814-North "C" Street Stockton, California Lodi, California r Manteca, California Tracy, California �4_1`` 4 -a.. Itsh ES-94M Revised W-2100