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1 APPLICATION FOR SANITATION PERMIT Permit No. . -------------------- VIA 4 Z_.2 `I ref! (Complete in Duplicate) '" " Data Issued 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 No. 549. JOB ADDRESS AND LOCATI, N_________________ _ -_1J�_/- / Y------------------------------------------------------------- Owner's Name------------------- r /Z-.------- ----------------------------- Phone------------------- Addre;ss---•---------------------- "- - ---------------------------------------------•----- ------------------------- Contractor's Name '_ - _ --------------------------------- Phone: Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: _ ___ Number of bedrooms Number of baths _1___ Lot size . •tea - -, - - Water Supply: Public system ❑ Community system ❑ Privatey Depth to Water Table __,07t. Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe Hardpan ❑ Previous Application Made: Yes No New Construction: Yes ❑ NoFHA/VA: Yes ❑ Noti*" TYPE OF INSTALLATION AND SPECIFICATIONS: i (No septic tank or cesspool permitted if public sewer is available within 200 feet.) Septi ',4k: Distance from nearest well_________________Distance from foundation--------------------Material compartments No. of ctts_ Size --------Liid de�--------------------------Capacity---------------------- - a r - Liquid __________-_, Dispo al Field: Distance from nearest well__ Number of lines -------Distance from foundation___le-_- - --.Distance to nearest lot line--- "\\ -: _____Length of each -_1(-------Width offrench._____ - (_ --- Type of filter materiali�c -.....Depth of filter material----/ _- -------Total length___.__ --,---f-0._- ---;f r ___r___.__.Distance to nearest lot line_ Seepage Pit: Distance to nearest well_��'y�--____----Distance from foundation_._��- � r Number of pits__.___`_____________Lining material___,- -___Size: Diameter__._. __--' t Depth--i!-- ---------- ----•%0 Cesspool: Distance from nearest well------------------Distance from foundation--------------------Lining material-------------------------------------— ❑ Size: Diameter-- ----------------------------------Depth--------------------------------- --------- -------Liquid Capacity----------------------------gals.t{ Privy: Distance from nearest well-_______________._._-__----___________________Distance from nearest building1 171 Distance to nearest lot line________.______._ .5 i ----------------------------------------------------------------------------------------------------------- 3 Remodeling and/or repairing (describe):--- '� " ` ... -------------------------------------•---------------------- -�•----------------------------------------------•------------------------------------------•------•-------- - -------------------•---------•-------------------------- ---------------------------•------------------- --------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Countyj ordinances, State laws, and rules and regulafi of the San Joa tical Health District. (Signed) --------------- f --------------------- (Owner and/or Contractor Ely:----------------------------------------....------------------------------`___ (Title)--.(Pl �. of plan. showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). FOR R DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--------- DATE j��-t-2� 3i REV11W'ED BY ------------------------------------------------------------------------------- DATE---------------- ----------------•-- UILDINGPERMIT ISSUED------------------------------------------------------- --------------------------------------------- DATE------------ -------------------- Alterations a nd/or_Tpcommendations------------------------------------------------------------------------------------------------------•---------- ---------------------------------•------------------•---------------------•--•--- . ,�.. -------�- ---- 1 .- ------------ --------------------------------------- - -- ------------------------- r FINAL INSPECTION BY------ - - -- -------------------- - ------------------ 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 , Revisea 1.57 F.P.CO.