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APPLICATION FOR SANITATION PERMIT Permit No..._Q.._ _A.l---- (Complete in Duplicate) Date Issued __!!�.�r --- 4424 Application is hereby made to the San`Joaquin Local Health District for permit to construct and install the work herein described. This application is made in compliance with County Ordinance N 549. .. f JOBADDRESS AN OCATION -=--------------•- ----------------------------------------------- .---------------- Owner's Name- s o -� _ Phone -:-•------ _ f -- -------------- -- w- Address------------- ' ----- -- --------- ----- --.-.7t--•----- -------------------------------------------------- ti, Contractor's Name ._-.__' - ---- -- ---• •- '�---------- Phone Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel [I Other ❑ ` Number of living units: 1r___ Number of bedrooms c3--_ Number of baths��_ Lot size __ 1 - ` -- -- ----------"--- Water Supply: Public system E] -Community system ❑ Private�epth to Water`Table 1 _ ft. Character of soil to a depth Iof 3 feet: Sand ❑ Gravel .4❑ Sandy Loam ❑ Clay Loam Clay ❑ Adobe ❑ Hardpan.C] Previous Application Made: Yes ❑ No W?New Construction: Yes no ❑ FHA/VA: Yes I [o ❑ �r TYPE OF INSTALLATION AND SPECIFICATIONS: &CIO G�L Ji ��'�G'U � (No septic tank or'cesspool permitted if public sywer is available within 200 feet.)) Septic Tank- Distance from nearest we xg-le-__Distan e qpm f arida i n__-_-` .----_.Material_ _ _. --------------- l No. of compartments._._.- ------Size__ ►-_ '. Liquid depth.-�___"-- CapacitY ��d __. } - J Disposal Field: Distance from nearer well.-. __ _ Distance from foundation-- -----__-Distance to nearest lot li e____ �,. of {fines___ ----- ----- ------ Length of each line----- AO----- J�--.Width of'trench----_ ' ------------------------ Number'` Type of filter material-/ _ De th of filter materi l_____ _ ___ ____Total len th____. See it: Distance to nearest well----------------------Distance from foundation--________,.....___.Distance to nearest;lofi line*_---------------.��, Number of pits----------------------Lining Taterial--------------- --...Size: Diameter-----------------------.Depth:--, ---------------------------- \1 Cesspool: ,y Distance from nearest well-----------------Distance from foundation._..-------_- Lining material----_;___--_------ ____________._. Size: Diameter ---------------De th----------------------=-------- Liquid Capacity_ a1s. Depth - ---=----- -- P Y g Privy: R Distance from nearest well------------------------------------------- ---Distance from nearest building---------_--------------------.------- -- ❑ Distance to nearest lot line ---------------- -------- ------ -- -•� s Remodeling and/or repairing (describe):------- �� / s- - ------------------------------------------- -----------•-------------------------------------------•------------------ ` ,_ --------------- i -----------------------------•-____--"--_-__--------------""_._---------"-"---____-_---___--._._..--------_-_-...-__---------•_-__---.__-_--____----•---_--.____-.-________•--_______.-________-___-:-----------------.-. I hereby certify that I have prepared this application and that the work will be done in accordance with San-Joaquin Comfy ordinances, State laws, and r sand regula ions of the San Joaquin Local Health District. w_. >. o ; _ _(A C n ractor) {Signed} g ,,,, - (,Title----- - -------------------------- By:- ----- ... (Plotplan, showing size of'lot, to ion of system in relation to wells, buildings, etc., can be place on reverse a}. P FOR DEPARTMENT USE ONLY " DATE---------------- -------- ----•------ APPLICATIONACCEPTED BY--------- - - --------- - - ---------------- - ---------------------•------------------\ REVIEWED BY - " DATE------- •F ---------------------------------------- BUILDING PERMIT ISSUED------- ------------- -- ---------------------- ------------- DATE-----------4� ----- -- Alterationsand/or recommen ations-------------- ----------------------------------•----------------------------------------------------------------------------------------------------- '4"--� . ----------------------------- 01 0 ---I-r--------- --- -- -r ------------------------------- Z ------------ -----------2 ------------------ ---4;_-_ �� -__--•-_--_-- ------------------------------------------------- FINAL INSPECTION BY::-- - - - -�------------------- --------------- ' " " - Date-- --=---�---- �� -------------------------------------------- SAN ----------- --------------------------SAN JOAQUIN LOCAL HEALTH DISTRICT - y 814 North "C" Streef 130 South American Street 00 West Oak Street 132 Sycamore Street x Stockton, California Lodi, California Manteca, California Tracy, California _ ES-9-2M Revised 1.57 F.P.CO.