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APPLICATION FOR SANITATION PERMIT Permit No. ._la_ (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 applicatiori is made in compliance with County Ordinance No. 549. JOB ADDRESS ANDLOCATION.... / - _ _ -------- Owner's Name--------- allGzl1 ------•------------------- = ------------------------------------- Phone Address l — ---------- ------------------------- Contractor's Name---------------------- ........---�------- -------------------------------------•---------- f ------------- Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: 4--- Number of bedrooms i-->1-.--'Number of baths ----)___ Lot size ----- `o ------------------------------ Water Supply: Public system 6//C"mmunity system ❑ Private ❑ Depth to Water Table ________ ft. Character of soil to a depth of 3 fee+: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe rdpan ❑ Previous Application Made: Yes El No New Construction: Yes El No FHA/VA: Yes El No ❑� _ 1 TYPE OF INSTALLATION AND SPECIFICATIONS: ' (No septic tank or'cesspool permitted if public sewer is" availablewithin 200 feet.) e i G c Septic Tan Distance from nearest well_______.-__Distance from foundation______ ___ ______.Material___-__--_.�____.__________._,��_____. No. of compartments--.__. �/ ./ -------- ----Size---- l Liquid depth ��—P CapacitY Disposal Fiel& Distance from nearest well------------------ from 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 length---------------------------------------- Seepage i Distance to nearest well-------0-__________Distance from foundation__-49-(___..Distance to nearest lot line- EV. Number of pits_----t---------------Lining material----rD.4--A'—Sze: Diameter-----3f� "_------Depth____ -- ------------------ i Cesspool: Distance from nearest well----------------- foundation--------------------Lining material---------------------------------- ❑ Size: Diameter------------------------ --- : Depth Liquid Capacity gals. `^ Privy: Distance from nearest well----------_--------------------------------------Distance from nearesf building----------El Distance to nearest lot line---=------------------ --`- - ------------------------------=-----------------•----------------- -- - --- - --------- ------- Remodeling an or,repairing (destribe�: ��C _ :------ ---------------------- ---- . -- 7 L 7 - ^ .------------------------------- -----------------------------=-----------•-----------------------------------------•-------------------------------------------•--•-•--------------------------------. -------------------------------------------------------------------- -------------------------------•------------------------------------------------------ -------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws—and rules and regulations of the 7San Joaquin Local Health District. Si ned a 7 __�a!-I _ �--- - ----------------- Owner and or Contractor By:------------ _ ---- -- r---- --- l (Title) GC S (Plot pian, showing siz lot, location of system in relation to wells, ui dings, etc., can be placed on reverse side). 4 FOR DEPARTMENT USE ONLY r APPLICATION ACCEPTED BY---T,--R_s�------------------------------------------------------------------------------ DATE--------- ------------------------ REVIEWEDBY---------------------------------------- ---- ------ DATE------------------------------------------------------------ BUILDINGPERMIT ISSUED----------------------------------------------------------------------------------------------------- DATE------------------------------------------------------------- Alterations and/or recommendations---------=----------------------------------------•--------------------------------------- ------------------------------------------------------------------ 3 P C- �_Q 1-N 1�H --1 -� ------------ } �-� za ` ------------------------------------------------------------------------- ------------------------------------------------------------ ------------------------------- ----- - -------------------------------------- - ------------------------------------------------ ✓------'------------------- -- ------------------------------------ --------------------- FINAL INSPECTIO_ BY:. ----------------- --------- { Date--------_--�_ �_ ._ S SAN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Street 132 Sycamore Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M , Revised 1.57 F.P.CO. i