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/I 3 APPLICATION FOR SANITATION PERMIT Permit No, (Complete in Duplicate) /G 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 AND LOCATION.0---`Jolg------, t--wl, Owner's Name------- yy� ------------------------- --------- - Phone //f �-------f -, c - .- Address---------- ---------------,-----p-- � Contractor's Name ---------Fr- `----- � �1 --------------------------------------- Phone-- -------- �. Installation will serve: Residence Apartment House ❑ Commercial ❑ Tra_i€er. Court..❑ Motel ❑ Other ❑ � Number of living units: -Z--- Number of bedrooms --� f r___ /y - -_-_ Number of baths -___---- Lot size -_-_--- ___ Water Supply: Public system [r<ommuriity system ❑ Private ❑ Depth to Water Table ---------ft. Character of soil to a depth of 3 feet: Sand Gravel ❑ Sandy Loam ❑ Clay Loam F] Clay E] Adobe 2 Hardpan ❑ Previous A lication Made: Yes AppE]i No New Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or`cesspool p;rmitted if public sewer is available within 200 feet.)i Se tic Tank: Distance from nearest weli_N-D-A[£'_-Distance from foundation_-- --_- P ��--•------.Material--------_'-��---"------- -------- � ---• �► No. of compartments.---- ------____--Size-- -`r-_3�-`-----Ligwd depth -11------Capatifiy--- ° D sal Field: Distance from nearest well------------------Distance rom foundation--------------------Distance to nearest lot line-------_----__-_- ° Number of lines-----------------------------------Length of each line------------------------------Width of trench----------------------------------- Type of filter material-------------------------Depth of filter material-----------------------Total lengfk------------------------------------------ Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line---_------------_ ❑ Number of pits--!-------------------Lining material-----------------------Size: Diameter----------------- - ---.Depth------------------------_------- Cesspool: Distance from nearest well-------------_--Distance from foundation--,_--------------------- Lining material-----------_--------_.----_--------_. ❑ Size: Diameter---I---------------------- ----------Depth----------------- ---------Liquid Capacity gats. Privy: Distance from nearest well-------------_------------- -------_Distance from nearest building ❑ Distance fo nearest lot line-------------- ---------------------- I -------------------- T Remodeling and/or repairing [descr�beJ:-----. ! __ ------ - ------ I !! - -------- x�4 ---------------------- ----___- --- ----- -� -- - - ---------- ----- ------------ ------------------------------------------ f; --------------------------------------------------------------=------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin County ordinances, State laws, and rules and regulations of the San Joaquin Local Health District. 1 r� (Signed)--- �° `-LC. -1d-----J.° _'- ------------------------------ ----------- .....I. Contractor) By:----------------------- •--------------------------------------------------------- (Title) -------------------------------------------------- -------- ---------------------------- -(Plot plan, showing size of lot, location of system in relati to wells, buildi s, etc., can be placed on reverse side). ,f E FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY---------'------ - --,}---- ----- ---------------------•--------------------------- DATE------------- £-A �. REVIEWED BY ---------------------- --- - f DATE BUILDING PERMIT ISSUED-------------- -------------------V-------------------------------- -------------------- ------ DATE Alterations and/or recommendations-------------------------------------------------•------------------------------------------: -----•----------- -------------------------------- - ---------- ------------------------------------------------�----- ----------- •-----•---------------•-------- ----------- S � �------------ -&-6--------5 -4 ------------------ ------------------------------ -------------------------------------------------------- ------------------ -- - --- --- ----- --- ------------ -------�------- -------------------------------------------- - FINAL INSPECTIO BY:.- - -•- -- - - Date------- SAN JOAQUIN LOCAL HEALTH DISTRICT i 130 South American Street 300 West Oak Street 132-Sycamore Street 814 Norfh "C" Street Stockton, California Lodi, California Manteca, California Tracy, California 1 ES-7-2M Revisea 1.57 F.P.CO.