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A_ APPLICATION FOR SANITATION PERMIT Permit No. _-------- 1 7•-_ Q (Complete in Duplicate) / 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. JOB ADDRESS A OCATI -__ _ ----------- �(// 4 Owners Name = -' -N !�' - Phone------------' -- - F a + - 3 - ---------------------------------------------------------------------- ---------------------------------- Contractor's Name------------------ ------•------- ---- -----•--- ------------- ---------- -----•---'-•------------------------- Phone Aparfinent Hou .------•---•-'._..-------•--------- •'1 Installation will serve: Residence '� se ❑ Commercial ❑ Trailers Court ❑ Motel ❑ ther ❑ Number of living units.:-I---_.,Number of bedrooms _-&_ Number of baths -_f-_.-,'Lot size _-- Water Supply: Public system' Community system ❑' ,Private ❑ 'Depth to Water Table -------- ft. t Character of soil to a depth of 3 feet:,' Sand El Gravel ❑ Sandy Lo��No ' Clay Loam [] Clay ❑ Adobe fflHardpan ❑ ' Previous Application Made: Yes # AP ❑. !No 900, New Construction; Yes ❑ FNA/VA: Yes ❑ No [] TYPE OF INSTALLATION AND-SPECIFICATIONS: (No septic tank or'cesspool permitted Zf public sewer is available within 200 feetf) I Q, Septic ank: Distance from' nearest well-- 6' f- fro f6u��tion_- :. ---------.Mater's No. of com artments_ Size- — p ---- ---- 4� Liquid � eptly--•----"�------------Capacity---- .-0`�--V= �` 1 Disp Field; Distance from nearest well Distance from foundation_l Distance to�nearest lot line_� -- - i Number of lints-_l.--Ai- ---- -- --Length of each line----------------�,�'--0-----.Width of french---=- .LrlType of filter mater !� ;---------- ^ Depth of filter material-- ----- -- - ---- Total length--_-____-_ �� Seepage Pit: ' Die fence to 'neare`st-well___` __ "" : '-'_Distance from"founds zeonDiameter-_ .Distance to; nearesfi lot line---------------- ❑ Number of pi#s-.--:_:-_^-- .-- ---Lining material---------------------- Depth --------------' Cesspool: Distance from nearest well------------------Distance from foundation_------------------Lining material-_----- ❑ Size: Diameter--------------=----------------- f-Depth------------- - ------ -------------------_Liqui.d Capacity-------------------=-------gals. Privy: F Distance from nearest well-'___ :__:____ ----------------------Distance from nearest building----_------------------- ___ r y - -----' 1" . ❑` Distance to'nearest lot I ne.-- ------------------------------------------------ _. -----=. Remode #p d {- g / iring (describe)------------------ lin and or re a ---••--- k------- ----------------- -------------- 3 ----- ---- ...... - - --------- y y re l' i - --------- --------- ---- -------- -- ----- -------�a--•------------ -------•---------=----------• - I hereb certif that I have Fred this application and that the work will be done in accordance with San Joaquin County ordinanc�,, fa a laws, and rules and egul ioQs of the San Joaq 'n Loca alth District. ' (Signed)- ------- ------- - ----(Owner and/or Contractor) f BY: --------------------- ---------------•--• ------------------------------------------------------ wells, buildings, etc., can be placed on reverse side). ; FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY- ' -REVIEWED BY ,- . - i :--- --' DATE_ -_• ' BUILDING PERMIT ISSUED--------- - -------------------------------------------------- DATE---- Al#era#ions and/or recommendations:-- ---_-- } , ,,,,g .� ---------------- ---------------- ,' { - ------------------------------------------------------- -------------------------- - rr ' - •------ FINAL INSPECTION BY:--------------------- •__ ----'-- Date �' i SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Sfreef 300 West Oak Street 132 Sycamore Street 814 Nor+h "C" Street Stockton, California Lodi, California Manfeca, California Tracy, California Revisea 1.57 F.P.CO. I