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I ,�7 { J a • APPLICATION FOR-SANITATION PERMIT Permit No. U / (Complete in Duplica+e) } Date Issued 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. All JOB ADDRESS ANA LOCATION--'- -r ,y... ...-.-; 10 -------- - - } !" Owner's Name---- -------------•---- -- - ------ Phone-----`-------' = 7 Address-------- --- --- ------�=------- -- _ _ Contractor's Name---------- --- c /- �.�- .� Ph ne.-.- ------- --------- ---------------------------------------------------------•------ Installation will serve: Residence ❑ Apartment House ❑ Commercial ❑ Trailer Court Motel Cher Number of living units: --/4-1- Number of bedrooms _- Number of baths I--_ Lot size --------- ��-�. Water Supply: Public system ,❑' Community system ❑ `Private ❑ Depth to Water Table_ ft: Character of soil to a.depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe, • Hardpan ❑ ! Previous Application Made: -Yes❑ iNo.❑ New Construction Yes ❑ - No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: , (No septic tank or`cesspool permitted if public sewer is available within 200 feet.) . ,6 4. , _..... .r , : - n _ Septic Tank: Distance from nearest well ~_ Distance from foundation_i-to- No. of compartments__--�-----------------Size _ --�rX.- ' Liquid depth----------------------Capacity--- 4�---LJA_-- Disposal Field:. Distance from nearest w0---- "--------Distance from foundation-----:2.6-_-----.Distance to nearest lot lin _-.--- �--.. Numoer of lines-1--.3- Length____ __________Length of each line-_7o---�_ _ ` /idth of trench----- __- --- -_-___ • -_---Depth of filter materiaf_/_ _-_-----_ - 0 pY g eriai- Total length ----------------------- Seepage ---------- Type o liter mat See a e Pit: Distance fo neareist well_Y-------------------Distance from 'foundation--------------------Distance to nearest lot line................. ❑ Dumber of p;fs----------------------Lining material-�--------------------Size: Diameter-----_-----------------.Depth------------- ------------ ! Cesspool: Distance'from nearest well_. --------------Distance from foundation------------------__Lining material-- -- ___----_,-__----.-.------- ❑ Size: Diameter--------------------.------- -------.Depth----------------------------------------------------Liquid Ca skit ais. - ,.. - Privy: Distance from nearest well--------------- ---------- Distance from nearest buildin building------------------------------------------ r.. ❑ Distance to nearest-lot line------------------------------ ------=------- ------ r ------------------- -- Remodeling and/or repairing r {describe )::---------------------------------------------------- _----------------- ---------------•----------••--------•--------------------------- ----------------------------------- ---•-------------- ------------------------- ---------------- ,------- -------= ----- ------ •-•---------------------------------------••----- --------------•-------------------------- - -------•------------------------------------- -----------------------------------_.._---_-_--__-----_----____-_-.__--_-__--- - f . _-__--.-----_-.-----------.--------------------------------------------- \ I hereby certify that 1-have prepared this application and that the work will be done in accordance-with San Joaquin County ordinances, State laws, and rules and'regulat' ns of the San Joaquin Local Health District. " • � 1 } �� (Signed), � ! `= ------------------- -------(Owner and/or Contractor) i ------------------------- :.... i Y• ----------------------------------------=------- •• ----------,-------------------------------------------------------------(Title)-------------- ------•-------- ---•--•------------------------ (Plot plan, showing size of lot, locations of system in relation to wells, buildings, etc., can be placed on reverse side). N FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------- = y ------------- DATE-------------------- -------------------------------------------------------------------BY--------------------------------------=°-------------------------------------------------------------------------------------- DATE-------•-------- -------•--- ---•-•--- BUILDING PERMIT ISSUI=D----------------- ----------------------------------------------------- ---------------------��--- DATE----•----------------•-------- Alterations and/o rec mmendati s: ------------- ----------- -- ----------- ��= -------•---------------- -- ---------- . wt•� •--------------- -------- ----------------�-^ .��`'---- -- --- ---------------- -- G•�---- --- -"---�---- ---- ---- f'------ - ----------------------------------------------------- 1 FINAL INSPECTION BY:-.- -- - _. 2_7 �------ =---- a.- --------------------- Date---- -- ---------- I SAN JOAQUIN LOCAL HEALTH 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-9--2M , Revised 1-57 F.P.CO.