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APPLICATION,,FOR SANITATION PERMIT Permit No. .._.,� .,�. b._ �;,` J' a�'�- „ , ' *ACS (Complete in Dupli ate) / } Date�Issued'.____l� �7 Application Is hereby made to the San Joaquin Local Health Districtfora-permit to construct and install the work he-tei6 described. his application is made in complian�Ce with County Ordinance No. 549. JOB ADDRESS A .LOCAT ON. !%.=_-f/G= r / �� - � ''� f - --------- -- --- . �_ Owner's Name �--- --"�-� ----- ------ ----- -- ---- Address -- f ,} Contractor's Nam��lee--•--t��..�--------------------------------------------- - -- ---- - --------------------------- ---------------- Phone._ .. ----------- Installation will terve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ i 1 1 Number of;liiv,mg units:,- __.__ Number of bedrooms� ___ Number of baths _____ Lot size _—�________._____ WaterS e pply: Public system ❑ Community system E] Z�Private Depth to Water Table ft. I Charactr of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam` Clay Laam ] Clay ❑ Adobe ❑ Hardpan ❑ Previous Application Made: Yes El l'�FICAATIONS: New Construction: Yes /�No E]No Yes E, No�' t TYPE OF INSTALLATION AND SPEC f ( o septic tank or'cesspool,�!permitted if public sewer is available within 200 feet.) ,L �eptic nk: Distance from nearest well-----------------Distance from foun'dation__-______-______-Material_______________-____--._______________________- No. of compaitmenpts--------------------------Size--------------- ----------------Liquid dep ll--------------------------Capacity-- Disposal I eld: Distance from nearest well_________________Distance from foundation________________� .Distance to nearest lot line----------- L Number of lines----- -------------- Length of each line-----------------------_"-I--.Width of trench----------------------------------- Type of filter rnatehal_____________________Depth of filter material------------------- --Total length_____-_____________-_:__________________" Q Seeps )Pit: Distance to n1esf1well__,-' _____Distance from f ndationl'_. Distance to nearest lot line%e!. mber of pits__ ____.______Lining material," _- L_.__.Size: Di I De th -------------- ----------- Nu ,J Cesspool: Distance from inearest well-----------------Distance from foundation--------------- Lining material______._-_---____-_-__--_---_-------_ Size: DiameCert--------------------------------------Depth---------------------------------- -_.-Liquid Capacity gals.. Privy: Distance from nearest well------------------------------------------------- from nearest ❑ ubuilding------- _ ------------------------ x ______________________- - --------------------- -- ----Distance to nearest lot lire----_ ;: - ----------- nan pairing._/ s, b ------ --- --------- --- -------------------------------•---------------------------•-- ' ---- --------------- -------------------------------------- t ------------------•------------- �--- ------- -- ------- ------------------------------------------------------------------------- I hereby certify that I have prepared this application and at the work will be done in accordance with San Joaquin County ordinancis, ate laws and rules and ie ulafions .of Ia San .. quin Lo Health District. (Signed)] -- ��--- -- _ " " _"-- -"-- f- -- _ -rrTf`--C-------- - A-(Owner a d/or Contractor) --------------------------------------------—_ Title--- ------- Plsiz� oo , g f tI ca I n?of system#'ih relation to wells, buildings, etc., can be placed on tirev r ( ot pIan, showin se.i'e). 'FOk,DEPARTMENT USE ONLY `� y APPLICATION ACCEPTED BY R --------------- DATE '------ --------------------- ---------------- REVIEWED - REVIEWED BY------------ '-`? = - DATE # BUILDING PERMIT ISSUED----- �""..'-- --------------------------------V,�------------------------------------- ------- DATE---------------------------------- ----------- -------------------------••---------•- ----------- ------------------------------------ -------------------------------------------------------------------- •--------------`�-• { --------------------------------------------- -`----•-----A------------------------------------------------------------------------------ '�� t --- ". -----------------------------------• ----- i � ----------------------------I-------------- ----------------------------------------------------------------- ---------------------- FINAL INSPECTION BY:-- -` `'w Date------.&57,l&57/�7----------------------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South Amaricen Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2K4 , Revises 1.57 FY-CO.