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- '-•ter APPLICATION FOR SANITATION PERMIT Permit No. (Complete"-in Duplicate) l l , " Date Issued -___/f-__�_7__�_ e / 47,R-—O Ll 6_OS Application is hereby made to the San Joaquin Local Health District for a permit to cons ruct and install the work herein described, This application is made .in compliance-with Cgunty Ordinance No. 549. �jSz3 z s C4--<,j f r JOB ADDRESS AND LOCATION_ __ ____ t _________ ____`7r,•t� -_" z__ "_ Owner's Name------ wX----- •------- ------- ----------- ---- - Phone.- •-------------•-------.-•-•-- I-. Address � i -----_ . - r Contractor's Name_____________ 0 ------ ------- ------------- - "--- ----------------- Installation will serve: Residence Apartment ouse ❑ Commercial ❑ Trailer Court ❑ Mot 11P Other ❑ Number of living units: Number of bedrooms __2— Number o baths ___L Lot size -----!7 --- " _*__________________._ Water Supply: Public system ❑ Community system ❑ Private Depthto W er Table _Dtt. =a Character of soil to a depth of 3 feet: Sand E] Gravel E] Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes 21;❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: � (No septic tank or'cesspool permitted if public sewar is available within 200 feet.) - Septic Tank: Distance from nearesT weli_,,(/_'7+'Uistan e rom . ____- y ter' •-- .. No. of compartments----------�---'_____Size_ _;/i__ .Liquid depth,,____/-___.'-----______Capacity_._.?--- &-___- Disposal Field: Distance from nearest weli: "YW.V'Distance from foundation_�D� -Distance to nearest lot FQh Number of lines-------- » _______Length of each line-_--____�_'-___-____ Width of french___.__�� _-�_____.__.___"_______- T e of filter material �k 1 Type Q [„Depth of filter material------ -----------Total length__-_______-?go-------- --- 1p Seepage Pit: Distance to nearest weft----------------------Distance from foundation----------------._..Distance to nearest lot line----------------- N ❑ Number of pits----------------------Lining material----_------------------Size: Mameter-----------------------Depth---------------------------------- Cesspool: Distance from nearest well-----------------Distance from foundation___________________ Lining material__---__._______.__._______.--------- N ❑ Size: Diameter------------- -----------.---------._s_Depth-----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------------------------------------------Distance from nearest building_-________.____--_____________.______._. ❑ - Distance to nearest lot'lire------------------------- ---------------------------------------••------------------------- - . Remodeling and/or repairing (describe):---------t------------------------------------------------- i------------------------------•------------------------------------------------------ -------------------------------""------•--- -------"---"-------------------------=------------ •----------•---•---.-----------------------------•----"------------------------------------ ---------=------------------------- ------------------------------------------------------------------------------------------•--•---------------------------------------------•------------------=----•---------------------•-.-------------------------------- , ----------------------------------------------------------- ---------------•---------------------------------------------------------------------- .-•-------•------------•"----------------------•----------- x I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Coun ordinances, State laws, and rules and regulations f the San Joaquin Local Health District. (Si ned 9 (Owner and/or-Contractor) .r (Plot plan, showingsize of lot, location of sys+em in relation to wells, buildings, etc., can be placed on reverse side). FOR ,EP.ART NT USE LY APPLICATION ACCEPTED BY---- d �_/ x DATE f REVIEWEDBY ---- ----------------------------- ----------------------------------------------------- DATE-- •------------------------------------ BUILDING PERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE--------------------------------------------------------- Alterations and/or recommendations-------------------------•---------------------------------------- -------"---..-.-----•-•----------------------•-•-------•---"-"-"•---------•---.."-_-- ------------------------------------------•---------------------------------------------------------------------- ---------------------------••-- M -----•--•---•--------------------------------------------------------------------------•-----------------------------------------------•-------------------•--- •---•------------------------------------------------------- --------- s - i FINAL INSPECTION BY-------------- -------------------- --- ------ Date--: ,� -+!' SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak 5+reef 132 Sycamore Sfreef 814 North "C" Street o- Stockton, California Lodi, California Manteca, California Tracy, California ES-9-21x1 , Revised 1-57 F.P.CO.