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1 APPLICATION FOR SANITATION PERMIT Permit No. _______ -•�S kx (Complete in Duplicate) 0/249 Date Issued . - — -f 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. JOBADDRESS AND CATION------ • •- -- ----- ---------------------------------------------------• .._. Owner's Name---i WA62061 -- ------ � - ---------------------------------- - Phone Address------ -- ---•-•------- - -- ----- ---- ------ --••-•------------••-•----- -- - ----------------------------------------- -------------------------------- Contractor's Name. -- --- 1®� ✓��` `� �---------- ------- Phone----------------------------------- Installation will serve: Residence VOOA—partment House ❑ Commercial ❑ Trailer /Court E] Motel F] Other E]Number of living units: _-/.__ Number of bedrooms 0?-- Number of baths dot size .X_ ----------------- Water Supply: Public system Community system ❑ Private ❑ Depth to Water Table If. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe A�Hardpan ❑ Previous Application Made: Yes ❑ No New Construction: Yes ❑ No @��FHA/VA: Yes ❑ No A-- TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) ptics T k: Distance from nearest well-----------------Distance from foundation---------.----------Material----------------------------------.-..----------- No. of compartments--------------------------Size--------------------------------Liquid depth---------------- ---------Capacity---------------- ------ 4 'sposa F' d: Distance from nearest well_________________Distance from foundation--------------------Distance to nearest lot line__________.__---- Number of lines----------------------------------.-Length of each line------------------------------Width of trench------------------------------ Type of filter material-------------------------Depth of filter material-------------------_ Tootal length_________-____-.________________---._----- 3, / A k Seepage Pit: Distance to nearest well_XDistance from foun tion--- .-----.D st n�� to athsfi_lot h_II � - Number of pits----- ----- _------------Lining material./�'�v_ ize: Diameter__) ...... Dep 040 Cesspool: Distance from nearest well-----------------Distance from foundation_________________ Lining material-____.____-_-_____-----__-___-______. ❑ Size: Diameter-------------------------- -----------Depth----------------------------------------------------Liquid Capacity----------------------------gals. Privy: Distance from nearest well--------------_---------------------------------Distance from nearest building---------------------------------------_-. _ ❑ Distance to nearest lot line-- ---------------------- ------------------------------ -----------=------------------------------------------------------- Remodeling and/er repairing (describe)---------------- —' y ---------------- ---- --------------------------------•---------------------- ------------------------------------------------------ ------------------------------------ --'-------------------•------ ------------------------------------------------------------------------------------------------- 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, anq rules and regu tions of the San Joaquin Local Health District. (Signed)----------------- --- - ----�---- - -- -------------- - - ----- - - - --------- - ------------------------ ------ Contractor) I . ------------------------------- Title i --- BY: ( ] � ---- ----= (Plot plan, showing size of lot, ation of system in relation to wells, buildings, etc., can be placed on reverse e). FOR DEPARTMENT USE ONLY APPLICATIONACCEPTED BY-- ---------------------------- ------------------------------------------------------------ DATE "" - -- ------------------------ REVIEWEDBY------------------------------- DATE--- :r------------------------------------------------ BUILDINGPERMIT 1SSUED--------------------•--------------------------------------------- ------------------------------ DATE = -------------------------------------- Alterationsand/or recommendations:------- --------- ----------- --------------------------------------------------------------------------- .....-------------------------------------------- ------- -- V9,C6N -- ----- r-! e _ d . . d r� c1.r ��rx -e =_�" , -� C e� ---- ------------------------------------------------•---------------------------------------------------- -------•---•--------- FINAL INSPECTION BY:------ -- --- - -- ------------------------ Date------------- - ------------------------------- 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--21x1 Revises 1.57 F.P.CO. 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