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APPLICATION FOR SANITATION PERMIT Permit No. _ -------- (Complete in Duplicate) pate Issued ._ !dlsl___.._ VQ`' 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 madein compliance with County Ordinance No. 549 . ----------------- JOBADDRESS AND LOCA IbN_._ -•----`---------------------------- ---------------•---------------•----- ------ JOB �`' Owner's Name------- -- IT ---_ ---------•--`---------------------------=----------------------------------------- Phone----------------------------------- 1 -------- Address_ _- ------------------------------------------------ ------------------------------------------ Contractor's Name - L- -------- '4_' ---- ---------i----------------- Phone.._.. l ! : Installation will serve: Residence Apartment House E]' .Commercial ❑ Trailer Court '10 pee❑, Of Number of living units: ___ Number of bedrooms _N -1_ �r ❑ = Lot size --------------- __I _ ____ Number of baths __ _ Water Supply: "Public'system jK Commu-nity system [I [Private Depth to Water Table" _s ft. Character of soil to a depth of 3 feet: Sand E] Gravel 171Sandy Loam El Clay Loam El Clay ❑ Adobe Hardpan El I Previous Application Made- Yes [I No New Construction: Yes.�No ❑ PNA/VA: Yes E] No TYPE OF INSTALLATION AND SPEC IFiCNS: (No septic,tank or'cesspool permitted if public.sewer is available within 200 feet.) ,/� Septic Tank: Distance from nearest well��-___Distan a from foundation ________.Material______________ A_ ----------- Capacity.-.-.? No. of compartments Size__ .__._ Liquid de th______ __ ..�� p {� q P• - ` ! ,rte-�'" '__._-_:_,Distance to nearest lot line__ _____. Disposal Field: Distance from nearest weil.___.___.__'__Distance from foundation____R .�- Width of trench___. _ _ Number of lines--------:- -- ---- - -- Length of each line-�__.- f--11-- ; Type of filter materialDepth of filter material-- __----------Total length------ __-- ..-_-- :.. „ . Seepage Pit: Distance to nearest well_____________'___:_-_Distance from foundation___._._____...___._.Distance to nearest lot line__-,7--- pits----------------------Lining material------ ---=----------- Size: Diameter--------------- Cesspool:. Depth Cesspool:. "Distance from nearest well----------------Distance from foundation--------------------Lining material___-____-__________,__--________--_-_. ❑ Sizer Diameter------ --- ---------------°'Depth-------------- -------- ------ Liquid Capacity- -------------------------gals, _ -------- -----= - . ----------------------------- --Distance from nearest building--------------------------------------- Privy: Distance from nearest well------ -- ❑ ,Distance to nearest lo't-line"°°-� �F�_:--- - ---- ---------------------------- ----- - ------ ------- ------ Remodeling and/or r pa -ng (describe)- '�_"' = -} -- dC 1 = ----------- --- ----------- -- - - - - -- I hereby certify that I have•prdpared this-applicatio and that the work will be do a in ccor ante with San again unty ordinances tate laws; a d rules and regulations of the San Joaquin Local Health District, r . K ---------------------------------------------Owner and/or Contractor) (Signed)----- -------------------- --------------------------- �.----- // Title By:. / - -�--------- ----------------- ------------------------------------------------- -----( � ) = (Plot.plan, showing size of lot, location of system in.relation to wells, buildings, etc., can be.placed on reverse side). + J FOR DEPARTMENT USE ONLY DATE-*— APPLICATION ACCEPTED BYs� - --------------------------------------------------- REVIEWEDBY ------------------------------------------ ------------------------ DATE__------------•--------- -------------------------- BUII_p1NG PERMIT ISSUED--- Alterations --------------,--------------------------------------------------------------. DATE --------------------------------------------------- --Alterations and/or re mme .----------------------------------------------------------------- - ""----•--•--•-----------------•----•----------------------- ----------- -------------------•---- --------•-------------------------------------- ---------------- - /f ------------------------ ----------------------- ---- --- ...................... -k--------------- - ------------ % FINAL INSPECTION BY:_____ Date------- (/ �'rt ff ----- SAN �. JOA UIN LOCAL HEALTH DISTRICT 130 South American Street 300 Wes+ Oak Street '132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 RP.CO.