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, APPLICATION FOR SANITATION PERMIT P. -Permit No. ------ (Complete in Duplicate) / 3 Date Issued i 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 N 549. JOB ADDRESS AN L CATION------: - - ----- '---•--- Owner's Na wr ""t _%i - ------ ------ - -- ------- Phone-------------- ------ Address----- .-Ili Contractor's Name- - -- ---- -- Other y " Phane.%�� '� = �= will serve e'nce artment House ❑ Commercial ( Trailer Court ❑ Motel ❑ Other ❑ Installation ❑ p Number of living units: __I___ Number of bedrooms ___Number of baths "" ___ Lot size _____ 00, -- ------ -------------- Water Supply: Public system Rl-_C mmunity system ❑ Private []'-Depth to Water Tables____ ft. Character of soil to a depth of 3 feet: Sand C] Gravel El Sandy Loam ❑ Clay Loam E] Clay ❑ Adobe �ardpan i Previous Application Made: Yes ❑1 No ew Construction: Yes ❑ No ❑ FHA/VA: Yes ❑ No ❑4 t TYPE OF INSTALLATION AND SPECIFICATIONS: ,a,.(No septic tank or'cesspool permitted if public sewer is available within 200 feet.) Sep Tank Distance from nearest well________________Distance from foundation---------------------Material-_____.__--_.________._____-__."-__.._..______.. No. of compartments-------------- - -------Size------- -------------=------:---Liquid depth_------------------------Capacity--------------- ------ Distance from foundation_ .Distance to nearest lot line_ _ __ spo aiI Pi�d �" Distance from neare t well-. , ,� , ,- f lines____ __-_ Len th of each line_ ".-------.Width of trend►:�___V_ """""""""--------- Number o � �°'� 9 �" .�1 Type of filter meteriaha+�. ' _ _ _ Depth of filter material- '�"____Total length__ ________"____________. Seepage Pit: Distance to nearest. well__ '_ _ ___ Distant fro �fo dation_____ . �_ Distance to nearest {of line-_______i " �►''� Number of pits-- --"-------------Lining ma#erial----.------- - _ ize: Diameter "------.Depth_ :----------------------- Cesspool: Distance from nearest well______-_____--__Distance from foundation___ _______________Lining material------------------------------------- ❑ Size: Diameter - `---- ------ ----------------------Liquid Capacity----- -------gals. -------- Privy: Distance from nearest well--_-.,-_:-'_: _--_-__---:_:-- -----------'--=-Distance fram nearest"building_______.____________________--__-----,--.�„ k ❑ --Distance to,nearest lot line. '-------------------------------------------------------------i--------------------------------- -- -------•------------- IN ["V, - 4 Remodeling and/or repairing (describe)---------------- -------- ----- N -------------------- --------•----------------------------------• _------------------------- c, c ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify t t I have prepared this application and that the work will-be done in accordance with San Joaquin County ordinances, State la and rules and regulations of ke San JoaLocal Healt District. e `"-- __-- -- Owl/!`r Contractor) r�-- . - -- - --- o��" - - t [Signed)_ �_ - Y 1 (Title]- � 1------------------------------------ 13 ' ---------------------•--------------•-------- --------------- (Plot plan, showing size of lot, location'of system in reld lon to wells, buildin , etc., can b'e placed on reverse side). t s s T FOR DEPARTMENT USE ONLY —APPLICATION ACCEPTED BY"-l--------------- -_--------------------- DATE --f 3-� 5 �------------- REVIEWED BY------------=------------------------------ - DATE_. -- - BUILDING PERMIT ISSUED-------------------------------I......... : --------- --------------------------rDATE------ ---- Altera ions and/or a dations:- - { iL(r ---------------------- --------- - -- ------------------------------•---------- "------------------------------------•------------ ------ •------- f FINAL INSPECTION -BY-.:n--- ---------- -- Date = ` 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,C).