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APPLICATION FOR SANITATION PERMIT Permit No. .__._._ (Complete in Duplicate) , Date Issued Application is hereby made to the Sari-,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. . rd- � ---• •----------------------------------�---JOB ADDRESS AND LOCATION-------------------------- -------- ----- - Owner's Name--------- ------------------------------------------ --- - --------------------- --------------., Phone-------------------------------- - ------------ h Address---------- 1 --------- -a _ _ --•------------------------------------------------------ j5 � I Contractor's Name---------FA R-R 1-5 A/ :r^/C_.` ...... ------------------------------------------ ---------------- Phone------------------ --------------•- Installation will serve: Residence Apartment House [I Commercial [] Trailer Court ❑ Motel ❑ Other ❑ - fI Number of living units: ___I _ Number of bedrooms ....Z_-Number of baths ____L_ .Lot size ------.7._- ----------- .f........... Water Supply: Public system [Community system ❑ Private ❑ Depth to Water Table ft. Character of soil to a depth of 3 feet: Sand ❑ Gravel [] Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe W—Hardpan ❑ Previous Application Made: Yes'❑ No [a�ew Construction: Yes EA--Wo ❑ I TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septic Tank: Distance from nearest well_ ,-r-°C ! �ditilC-Distance from foundation - No. of compartments.--- ..---.- ---Size--- t_ vlf_ - ---.... depth...____ . .P_ Z_-- apaci#y__ _ ----____-- Disposal Field: Distance from nearest well__ZVb ,&`Distance from foundation_-.7G-........Distance to nearest lot line---,4(- Number ine___Number of lines______________L. Length of each line___�,?_Q....__ .t3_a_�Width of trench--------;7__ Type of filter material-----,� y :R'Depth of filter material_._.../__16----------Total length__-._ - d- _ r Seepa it: Distance to nearest well..A/o_AX_--Distance from foundation---i-RP------_Distance to nearest lot line---f M Number of pits---------f......---Lining material-_ .t,_ .Size: Diameter___3_______:__ Depfn [ Cesspool: Distance from nearest well----------*-...__Distance from foundation_-------------------Lining material-------------------------------------- ElSize: Diameter------------ - -----------------------Depth----------------------------------------------------Liquid Capacity--------------- -_---gals..,- Privy: Distance from nearest well-------------_---___---------------------------._Distance from nearest building----- ----------------------._--_-._..___- ; ❑ Distance to nearest lot line_------ -----------------------------------------------------••--------------------------------------------------------------------- ----- Remodeling and/or repairing (describe:_...___ ,1 f..7-A�:: -------------------------------------------------------------------------------- --------------•------------------------•---------------------------------•-------------------------------------- --------------•-------------------------------------------------------------- ------------------------------ f _______ ----••-----------•-------- ------------------------------•--------------------------- ,. 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 San Joaquin Local Health District. (Signed) - J�-�--�-�- '. �' Cr--------------- ----------------------------------------------------- -_. w�her and/or Contractor) ------ - --------- BY� �- --G� - g------------------(TitleP_._ _ =c ` ------------------------------------ (Plot plan, showing size off toocation of system in relation to wells, buildings, etc., can be laced on reverse side). FOR DEPARTMENT USE ONLY _ rh �. APPLICATION ACCEPTED BY____ ___ __ _ ____ - ---- --------------------------------------- DATE---------------- ka--------------------------------- ------------ ----------------- ---------- DATE--------- r _,REVIEWED BY-----------------------------�-_-- - ��- --------------------------------------------------------- - •-- - ---------------------------- DATE- Alterations ATE } _ BUILDING PERMIT ISSUED---------- ------ - --------Alterations and/or recommendations-------- -- ------- --- - ----...---------------------------------•---------------------------------•----•-----••-•--•------------------------ ---------------------••----------------------------------------------- - ------ ------------------------------------------------------------------------------ •-----------------------------------••---------------•-- FINAL INSPECTION BY:.._.— 71P -- Date... D. r'� u -------------------------------------- SAN AQUIN 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 E5---9-2M 145446 ATW=> 12-54 f