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7 /0 'lu APPLICATION FOR SANITATION PERMIT Permit No. /Of (Complete in Duplicate) Date Issued /y�r Application is hereby made to the San Joaquin oaquin Local Health District for a permit to construct and install the work herein described. application is made in compliance with County Ordinance No. 549. ------------------- JOB ADDRESS AND LOCATION---------------7;7s—.-------- Owner's Name-------------/--" ame------------- /. -—/- -------------------- - -- ----------------------------------- ----- Phone------------------------------------ aAcio--------------- C -1 Address_.-------------------f� -----------F 71 7-------------- S__7D-i_-,-el� ----------------------------------- Contractor's Name-----------, ---------------------------- Phone_4emk_d��- Z),7 '61 Installation will serve. Residence's--- ----i- partmenf House M Commercial E] Trailer Court E] Motel El Other I ----------------- Number of living units: Number of bedrooms J---- Number of baths -1---- Lot size Water Supply: Public system Community system [I Private E] Depth to Wafer Table ,/.a ft. Clay E] A Hardpan Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam [] Clay Loam [] Previous Application Made: Yes [] No New Construction: Yes Ej NO FHA/VA: Yes [I N�e TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool permitted if public sewer is available within 200 fee+.) Septiceank: Distance from nearest Distance from foundation----/j---------Materia�----.-72 ?/-CA ------------- ----------Size___ - '57, ---Liquid d.p�h__-4:7e.... ......capacity-----00_0----- No. of compartments------Z :)un�lation /41./-A-__.Distance to nearest lot 1111 0 -Distance from fi Dis al Field:. Distance from nearest well_.A4kJff- of trench_____ ___-------------- Number of lines-----------/--- ------------Length of each line------ ------Width 9 7>-- 1-----X?--_____._Total length-------- ------ ----------------- Type of filter material----- -"' e---D�pfh of filter materia 11 Distance to nearest well____1VoA)F--Distance from foundation---- Distance to nearest lot line____/j----- Se e Pit. — / :Is ----------------- ---/PZ Depth-_- ---- Number of pits-----/-------------Lining maferial--- --Size: Diameter_____ ------ 1; X Ir Lining material__-____________________-_.___________. Cesspool: Disteance from nearest well_________________Distance from foundation._.---------------- ------gals. El Size; Diameter---------------- Dept h...:1----------------------------------------------Liquid Capacity-------_------------- rice from nearest building_____--___--______.,_________- 3 -Z--------------- -------- Privy: Distance from nearest well--------------/I--------------------------------:Disfa Distanceto nearest lot line----------------------------- - -------------- ----------------------I-----------------------------------------------•----------------------- Remodeling --------------------------------I----------------------- Remodelingand/or repairing (describe)----------------------------- --------------------------------------------------------------------I-------------------------------------------------------- ---------------------------------------- ------------------------------------------------------------ ----------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------'_1 -- ----------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- --------------- 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, s, an. les nd r7ed7ans of the San Joaquin Local Health District. d). (Owner and/or Contractor) (Signed)---------------------:4 ------ ----- ----- --------------------------- - ..... ---61 - By:------------------------------------------------------------------- ---- ------------------------ -------------- to w- i- (Plot plan, showing size of lot, location of system in relation�Oyw�ells, ,idings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY----------------------------------- -------------- ---------------------------------------------- DATE-------------------- --------- -------------- -- -------------- REVIEWED BY------------------------------------ ------------------------------- -----------------------------------------------------• DATE------------- I------ ----------- BUILDINGPERMIT ISSUED-------------------------------------I-- - - ---- -- ------------------------------------------- DATE----------- ---- ---------------------------------- i --------------------------------------------------- Alterefioni and/or recommendations:------------------- ! --- ---- -- ------------- 6------------------------------------------------ ----------------------------------------------------- --------------------- -----------------------------------I------------- -------- ---------------------------------------------- --------------I--------------- - ----- --- --------------- -----------------------------------------------------------------------I-------------------- ---------------------- - ------ --- --------------------------------------------------------------------------------- ------------- Oel-lir----/---. -.-- -_ -_ ---- -- ----------------------------------------------------------------------------- --- ------------- --I-------------------------------------- ------ -------------------------- )_ --------------------_ 4 FINAL INSPECTION BY:_______-- ---- -------- Date-----------4=-r--- ------ ----------------------------- SAN JOAQUIN LOCAL HE LTH 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-4-2M Rovisec 1.57 F.P.00.