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'fy, J APPLICATION FOR SANITATION PERMIT Permit No, IP-q-:1.7 2' (Complete in Duplicate) NAMDate 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. 3 7— JOB ADDRESS AND LOCATION- 4/ LV ju ` ,. Owner's Name_ a Phone--,* -- -��------------------- 1 _-------—i----------------------y-1-� ------� 1 �"'� Contractor's Name----------------- ---�d�-------------- ---- -- ---- ---- - Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court• ❑ Motel ❑ Other ❑ Number of living units: -- Z 'Number of bedrooms _- Number of baths __-_--_- Lot size Wafer Supply; Public system ❑ Community system ❑ Private ®--15'e-pth to Water Table 417 ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ —Sandy Loam 'Clay Loam W Clay [] Adobe ❑ Hardpan ❑ Previous Application Made: Yes ❑i No X New Construction: Yes No ❑- FHA/VA: Yes ❑ Noj< TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank oricesspool permitted if public sewer is available within 200 feet.) 01 $_ Septic/,4nk: Distance from nearest Well-140 --- DistadWtfrtftndation_--1Q_-_--__---.Material_I ------------- •----- --No, of compartments---__` _ ____----__`Size___ Liquid depth_____' __ Ca acit _-_-- ----_-_� c '`�---------- -- P YDisposal Field: Distance from nearest well- J ----_.Distandafion---/vr----__.Distance to nearest lot fine-------------_- L1d' Number of lines----- - _.�-_ Length of each line'{----"q1_O--------------- Width of trench------�-�ii_ -----__-_ Type of filter materiel-_."__ of filter material---_.1f�`_,___Total length______4. - .Seepage it: Distance to nearest well- Distance from undation---- ----- - - --. -_ Distnce to nearest lotNumber of pits.-I1---__--. material - - - --- _-----Size: Diameter__.-- -----Depth_----- " 3 - --------------- Cesspool: Distance from nearest well-----------------Distance from foundation-------------- Lining material--------------------- Li -.--__----___--. Size: Diameter----I__--__-----_--- -- -------. Depth-- --------------------------- ---------------------Liquid Capacity----- gals. •�� Privy: Distance from nearest wel! '_-__ Distance from nearest building Distance to nearest lot line------------------------------------------------- i ----- ---------------------------------------------------- RemodeNng and/or repairing (describe):---/<-2)U ------- -- - - --- - i p --------------------------------------------------------------------------------------------------------------------------- ------------------------------'-'---------------------•--------k-----------`----------------------4------------------------------------------------------------------------------------------ ------ --------- I hereby certify that I have prepared this application and tha the work will be done in accordance with San Joaquin C-ounfy ordinances, State ws, a rul and i regulaf ns of the San/Jouin Local Health District. (Signed)_ = - ------ --- -------- ------------ ------------------------------------ Owner and/or Contractor] Plot plan, showing size of lot, locatio i of system -- relation ------------------------------Title Y' - P 9 i y elation to wells, buildings, etc., can be placed on reverse side). FO EPARTMENT USE ONLY APPLICATION ACCEPTED BY--- <------_ DATE------ ---- ----------- ------ REVIEWED BY °----- DATE ------------------------------------------------------------------------------ BUILDING PERMIT ISSUED-------------------------------------------------------------- ----- ------ ------------ - ------------------ DATE------ ------------- Alterations and/or recommendafions:_y— :--_---_-.--__- --------------------------------------- 1 ---------� -------- ------------------------- ------------ -------------------- ---------------------------------------------------- -------------------------------- ---------- FINAL INSPECTION BY:.------PSAI,------ Date-- SAN ate-SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 1 300 Wes+ Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California E5-9-2M • Revised 1-57 F.P.CO.