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i 5 APPLICATION FOR' SANITATION PERMIT Permit No. �•• I)� (Complete in Dup cate) .1 y Date Issued ---- Application is hereby made to the San Joaquin LacaI Health District for a permit to construct and install work described. This a lication is made in compliance with County Ordinance No. 549. C 33x£. A-)OE C ,C�f��' ' 7 JOB ADDRESS AND LOCATE N:______ ,rte Owner's Name_ ---- - -- - ----=------------- -- - .- Phone_---------------------------------- --------- Address -�fh �" ---- ----------------------- --------------------------------•---------------•-------------------------------------------------- -------•------. f Contractor's Name________,___ , � f ------ ----------------------- ----------- Phone ---------------------------------- Installation will serve: Residence ❑ Apartment House I_ Commercial ❑ Trailer Court ❑ Motel -��.�.t� ❑ Other ❑ ' Number of living units: _�____ Number of bedrooms -f - - Number of baths ____ _"Lot size .__ _ ' 7 y -------------- Water Supply: Public system ❑ Communit system � Y y ❑ Private Depth to Water Tablet.-ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy LoaClay Loam ❑ Clay ElAdobe ❑ Hardpan E]Previous Application Made: Yes El' No New Construction: Yes [ No Ef FHA/VA: Yes ❑ Nc,�X TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest wef!____ foundation ` t �___Distance from _ _� ' ' E �- - y - --Q------- -.Material-----� _ No. of cam artments___ - P s ---------- ---cSize:- _- -� X.S77 Liquid depth - _Ca acit ------ ------ Y t rP y Gu Disposal Field: Distance from nearest well C�_�Distance from foundation_ _ ' .Q Number of lines _ - _'- %'- Len th of each line_______ ;.- ---Distance to nearest lot lin __ _ _ m g Gi-�_y Width of french___,,? Type of filter material__ ------------------ ��- '_:-_Depth of filter material____ __ ____--------- from foundation______-___-_-_____.Distance to nearest lot line_______--________ �• E ❑ Number of Pits_____________________Lining material----------------------- Diameter___________------- -- _Depth---------------------------- Cesspool: ----- � Distance from nearest well---- -------------Distance from foundation-----_--------------Lining material__________-__---___._ El Size: Diameter---------------- --------------- ----Depth--------------------------------------- ---------Liquid Capacity--------------------------- als. Privy: Distance from nearest well__________ ------------------Distance from nearest buiidin g 9 ❑ Distance to nearest lot line________________-______ -------------------------------------- Remodeling and/or repairing (describe):.......... ------------- •.. -------------------------------------- ----------------- ------------------------------------ -------------------------------------- ------- ---•--------------------•-------------------------------------------------- s 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, and rules and regulations of the San Joaquin Local Health District. (Signed)---- >G _ J�'--- y � ----------------------------------------------------------------------------------------(Owner and/or Contractor) ---------------- - --------------- FOR __ )--------- (Plot plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be placed on reverse side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED.BY------------- DATE_ REVIEWED BY__._ ------------ BUILDING PERMIT ISSUED `'t' --- -- - ---- --- ------------- --- DATE-- . - --- ---------------------- -- ------------------ D Alterations and/or remend 'ons: ,----� / A f/-------•-------------------------- - -� ----- -------- ---------------- ----------------------- ------------------------------------------- --------------------- - --------------- r FINAL INSPECTION BY:. _'' � -------------- Date-------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" 5+ree+ Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2K4 Revised 1-57 F.P.CO.