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r APPLICATION FOR SANITATION PERPvIlT Permit 1, (Complete in Duplicate) Date Issue -�� 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 Ordinance No. 549. � a: JOBADDRESS AND O TION-•-- = ---- --a------ --------- ----------- -------------------------------------------------------------------- Owner`s Name-----_-- --------------7- _. Phone Address --s,-r,-,--f U �6/ =----------------------------------------------------------------------- ------------------- f Contractor's Name----------- ---------=------------------------------------.----------.-------------------------------------------•- Phone-_?- _ Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [j Other ❑ Number of living units: _1______ Number of bedrooms _x___ Number of baths ------- Lot size __ __ _ _ __ ________________________ Water Supply: Public systemCommunity system '❑ Private ❑ Depth to Water Table ________ ft. .Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe-Ir Hardpan E]Previous Application Made: Yes E❑ No New Construction: Yes ❑ No I TYPE OF INSTALLATION AND SPECIFICATIONS: i - (No septic tank or cesspool permitted-.if,public sewer is available within 200 feet.) Sept ic"Tan k:,.r,_ '`- Distance;!feom,ynearesf well_______________Distance._from foundation--------------------Material_:____________________-_____________________- lot No.`of com partrnents--------------------------Size--------------------`-------------Liquid depth--------------------------Capacity L Disposalf�el Dls#ancd from nearest weil_________________Dlstance from foundation________ _ Distance to nearest lot line________.-.-___. fiiiriber`of-lines-----------------------------------Length of each line------------------------------Width of trench--------.-------------------------- Type of filter material---------_---------------Depth of filter material__________________ _Total length------------------------------------------ "6n __________._________ _-______-______-- .li: Se aqe Pit , , Dist$ ce.to nearest well_____________________Distance from fou ation____�__._____.Distance to nearest lot line____ j rNumber of its_____ ____ ________Linin material � S.ize: Diameter_____ De th____ s'_ __ `* '` rx p 9 - p , Cesspool Distance from nearest well_________________Distance from foundation,--------------------Lining material---------------------------- ❑ ' _De th--------------------------------------------------- Li uid Ca aciSize: Diameter------------------------------------- pq P tY- -----------------------gals. Privy: Distance from nearest.well-------------------------------------------------Distance from nearest building_.___-___-- ..___________ _.__._____� ❑ Distance to nearest lot line------------------ . RImoling and/or repairing describe:____-__? -�_. _ _ __ _ - sr - .- ,_...... -- - -------------------------- ----�-- -____�----------- - ---- -- - ------------ ------------------- -- ----------- ----- `---- ----- �.- - � ;,�- � - --- --- =�' - --- - ------------ _Z - _- --- --- ,��----- ---=Y---------------- ---------------------- I herebycertify +hat I have prepared t`is application and that the work will be done in accordance with San Joaquin County "ordinances, tate laws--and ru! and�egu°lations of the San 6aquin Local Health.:District. q � � '+ 3- _____Owner and/or Contractor (Signed)--------------- - = = w- ( ) By:----------- ----------- u: -------------------------------------------(Title)_ .� - (Plot plan, showing e o o , locati nAS-4-- FOR min relation to wells, buildings, etc., can be p acT�'ed on reverse side. DEPARTMENT USE ONLY APPLICATION ACCEPTED BY �`� - ---------------------------- •------------------------- DATE_ .,--_-------------- REVIEWED BY---------------- ----------- -�-------------------- ------------ -- --------• ; „ A-,. . DATE---- BUILDING PERMIT ISSUED--------------«'�---------------------------------- --------------------------- DATE----------- �------------------------------ .------------- ----- - ? Alterations and/or recommendations:--------------------------------------------------------------------------------------------------------------------e-------••--------------------------•--- ---------•--•----------------------------------------•------------•---------------•-------------------------•----------------------------------------------------------------- •-•--------------------------•---------------- i ----------------------------------------------------------------------------------------- ------•-----------------------------------------------------------•.._..---•-------•------------------------------------- •------- 1 ------------------------------------------------- ----------------------•--------- --- ------------------------------------------ ----------------------------------------------------------------------------------------- FINAL INSPECTION BY:---------- --•---------------------------------------- Date.- ---------- `j' /.rte J f / -----------------------•------- �! SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 1.32 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California VES-9-2M 8-51 Revised W-2100 ,f